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.
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*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.