Wednesday, December 05, 2007

What to do when the SSRIs don't work

I've known my patient S for years. She is a high energy sort of person, or at least she was until her underlying depression got the better of her once again during these past few months. She'd previously had good luck with Celexa (aka citalopram), so we'd restarted that antidepressant with some initial success. Today, however, she noted it just wasn't enough. The anxiety was better, she no longer felt bleak. The problem though...she didn't feel much of anything at all, stuck instead in a 'wrapped in cotton' sort of emotionless feeling, no enthusiasm or motivation to get anything done at all.

So what to do when the SSRIs* don't work. There's an array of therapeutic options with more or less good science behind them which include adding a second antidepressant such as Wellbutrin or Remeron (mirtazepine), an anti-anxiety agent called Buspar, a stimulant such a Ritalin, or a touch of T3 (triodothyronine). Given that S missed her joie de vivre most of all, after much discussion I pulled out my rx pad to write for Wellbutrin to shore up the dopamine in her brain. She mused about her longstanding depression as I wrote--"been depressed since I was seven."

Bingo, what was I thinking? Depressed since childhood, unresponsive to conventional antidepressants...hallmarks of bipolar depression. I pulled out a copy of the Mood Disorder Questionnaire, a rapid screen for bipolar disorder. The first 13 yes/no questions ask about behaviors common to this disturbance--7 positive answers are highly suggestive of the diagnosis. S answered yes to 12!

Never mind about the Wellbutrin. I wrote a prescription for Lithium, and S was delighted to finally have an explanation for her lifelong struggle with shifting moods.
*SSRIs or selective serotonin reuptake inhibitors boost the action of a brain chemical called serotonin by preventing its removal from the gap or synapse between one brain cell and the next one down the circuit. These drugs include Prozac, Paxil, Zoloft, Celexa, Lexapro, and Luvox.


janeywan said...

I take celexa and seems to work fairly well for me. Right now with all the stress and what not with my folks I could probably bump it up. Need to get appt with PCP. It's on my list.

Did the test and thank god I'm not bi-polar. I think I have situational depression/anxiety.

Dr. Smak said...

I have to admit that I'm a total wuss when it comes to bipolar and it's meds. I don't do any of it, possibly because my faculty during training strongly advised against it. I've been tempted more than once, but in the end I always turf to psych.

Have you had any negative experiences with treatment of bipolar?

JeanMac said...

Lucky her that you are sharp.

Judy said...

As I read along through your considerations of what to do for your depressed patient (before you identified Bipolar) I expected you to talk to her about exercise, stress management techniques and counseling - totally effective interventions for many struggling with depression. *Thanks for all the good info you generously take the time to share with all of us.* Judy, RN, LPC

Femail doc said...

JW: How well I know how the aging parents situation can stress inner resources to depression and anxiety. I feel like you and I and all in this situation have to be extra careful to take good care of ourselves. More Celexa might be helpful!

Dr. S and Judy, RN: Great points both. I'm going to take them up in subsequent posts.

JM: Thanks for supportive comment. I'd like to get to the point where I always think to screen for bipolar first visit so common is this variant on depression.