QUESTION:
Dear Dr. Heller,
I have been suffering from a serious mood disorder for approximately three years. Before this time, I was an excellent achiever (I completed medical school (near AOA) at University of Miami and was seven months away from completing a pediatric residency). Once the mood disorder hit, I was required to resign from my residency. My medical career is hanging by a thread. I saw a primary care doctor who diagnosed MDD versus dysthymia (I was "numb" inside - incapable of feeling pleasure, slow, no interest, tired all the time, and unable to concentrate well).
I was started on 10mg, then 20mg of Prozac at that time. That was a while ago, but as I remember it just made me feel "flat" and not much better. I was referred to a psychiatrist. At that time I was diagnosed with MDD with atypical features and went through several medications: Wellbutrin (initially worked very quickly but then agitation and lability/irritability ensued), and Effexor (almost the exact same result but developed dysphoria). I was on maximum doses of both at one time - unsure when and why. Again it initially worked great (within a week) but then I became dysphoric again.
Due to a move, I saw another psychiatrist who thought I had "anxious depression" versus "dysthymia and GAD", and I was started on Celexa 20mg and BuSpar 15mg with a plan to titrate up the BuSpar to 45mg. I developed, (what I interpret as) a dose-related increase in drowsiness and dysphoria, to BuSpar. It was stopped, and Celexa was increased to 40mg. There was no response, so Celexa went back down to 20mg and Klonopin added 0.5mg/day. (I must comment that some of these changes were quick, and this period was kind of like a whirlwind between 11/2000 and 2/2001).
Finally I developed severe "depression" - dysphoria - that required admission, due to Klonopin overdose. At this time, I was diagnosed as "bipolar II" due to "hypomanic" episodes on Wellbutrin and Effexor, as above (I did have euphoria, increased energy for a few days, but no sleep or thought disturbance I can remember). I stayed on Celexa 20mg, and stopped Klonopin, and added Lithium at 600mg. A week later, I had major hypomanic episode for 4 days or so, until lithium increased to 900mg, made me feel drugged. The dose was lowered back down to 600mg, and "hypomania" gone.
I began developing mood instability - dysphoria - again, Celexa was switched to Serzone, with no effect. I attempted to bump up the lithium, with no effect. Finally I was admitted again for severe dysphoria with suicidal ideations (and very hostile/violent fantasies/daydreams, not about people I know, and not actual impulses). I was diagnosed as "Bipolar II, rapid cycling type, most recent episode mixed". I was taken off all medications and was started on Depakote which was rapidly increased to 1250mg/day. Then Zoloft 50mg/day was added. I was released three weeks later.
That was almost three weeks ago, and I still have pervasive dysphoria. In the interim, my psychiatrist took me off Zoloft due to headaches, and felt dysphoria may be due to SSRI-induced mood destabilization (like in bipolars). It was replaced with lithium at 600mg. I went in a depressive slump again, and Depakote was increased to 1500mg. The depression got worse. I just decided to stop all medications, and began drinking EtOH (3 shots that night) to dull the pain. I felt better almost immediately and for three days after. Then I got worse again (dysphoria).
I don't think I have "bipolar II". I've never really felt great. I've felt unstable - usually between normal mood and severe depression. It changes hour-to-hour and chaotically. I also feel I fit into the BPD diagnosis by DSM criteria. I would diagnose myself as having MDD, atypical type, with a dysthymia versus BPD. But I am discouraged, as the drugs you mention that work for BPD, with the side effects (Prozac, BuSpar, Effexor) all have done poorly for me. I feel very discouraged and don't know what to do. It's been three years, and I'm no better. I just want to know what do you. What does my history sound like to you?
ANSWER:
[Dr. Heller's response it forthcoming - please check back. Thank you for your patience.]
