Q:  Depressed and Spiraling Down, Asks for Advice

I am so tired of trying drug after drug and being a guinea pig. I am bipolar rapid cycling. To top it off I have become an alcoholic . I started drinking to control my symptoms and now I am addicted. I went thru a 90 day treatment program and came out drinking harder than I ever had. I feel like life is just against me. I dont know how to get out of the trap I am in. Life seems unsurmountable and even if I quit drinking my life is still a shambles. I am on a cocktail of drugs just to function semi-normally. I am trying hard to keep down a job and tolerate the stress. For 5 years we (my psychiatrist and I ) have been trying every different drug under the sun. I am tired . I know my risk of suicide is greater drinking. I am impulsive even when not drinking . Thing is I am not sure I care. Bipolar disorder is knocking me down and I feel pinned . I take 4 different drugs to just feel human . Lamictal, Seroquel, prozac and strattera. The depression is killing me . Not manic anymore . Just spiraling down and down. Any advise would be appreciated. But if you dont answer I understand I am not worth much.

Allison
 

Dear Allison –

Well, where to start?  There are so many openings here, opportunities to change things for the better.  For example, your depression is painfully obvious, in such thoughts as “I understand I’m not worth much”. thoughts like that are extremely amenable, under the right circumstances, to a particular kind of psychotherapy called “cognitive/behavioral therapy”.  Now you might say “oh, I’ve had that before too”.  But if you have not had the opportunity for training in this technique to the point where you could hear a thought like that and know what an obvious target it is for intervention, then whether you have “already had it” or not, there is more to be gained from that technique.  And that means there is a tool out there for you which has not been fully explored or optimized yet. 

Likewise, if you go through a treatment program and come out drinking harder than ever, we could easily conclude that the treatment program was not effective for you (boy, is that ever an understatement).  In other words, that particular program didn’t work.  This doesn’t mean that some other program for management of your alcohol use might not work.  It does seem to mean that the one you just went through doesn’t work for you, and can be written off as ineffective.  However, it may have been ineffective because of other things that were going on at the time – such as the profound depression you are clearly in now.  So even now, a program like that still can’t be “written off” entirely.  It might work quite well under different circumstances. and in that, lies a general message, as follows. 

Sometimes treatments that could otherwise have been effective “don’t work” because of the presence of some other factor.  That factor could be alcohol, so the previous treatments which were underway when alcohol was also a big problem might have failed not because those treatments themselves are ineffective, but because of the alcohol use at the time – which can promote continued cycles into severe depression as well as mania. 

But, you may be thinking, how can I get off the alcohol if my mood symptoms keep driving me to it?  Don’t I need to get the mood symptoms treated first? As you are learning, sometimes one just has to go after everything at once, because it is too difficult to identify which is the chicken and which is the egg.  Now that we are in the barnyard, let’s come around to guinea pigs. 

First of all, this sense of being any “guinea pig” is a common one, and an understandable one, and perhaps even more particularly likely to come up, as a thought, when you are depressed.  Because the “guinea pig” idea is really an expression of frustration at the necessity to keep trying one thing after another without certainty that it will work. at the same time, as part of that “cognitive” intervention, it’s important to recognize that this thought, while understandable and even expectable, is not actually helping you, and is probably making things worse.  That’s the cognitive trick, in part: one examines thoughts like this for their value.  The hard part is then to let go of such thoughts, shifting your attention elsewhere.  Often that is the “behavioral” part, where you have pre-planned strategies for what to do with your attention when it is tending to go off in the direction of thoughts like “I hate being a guinea pig”. 

Finally, although this is somewhat controversial, not fully agreed upon by all mood experts, lots of mood specialists think that antidepressants can promote cycling.  In other words, they can be working against an otherwise potentially effective mood stabilizer, making it less likely that the mood stabilizer will do the job.  The good news there is that this often opens up many possibilities, going back to medication approaches (and non-medication approaches, like AA and cognitive behavioral therapy) that were not affected previously, but were used at in conjunction with an antidepressant.  In my experience, it is actually quite common to go back and find that things work much better when antidepressant is no longer in the picture.  Indeed, I think this is so true, that I actually find myself hoping that a person who is expressing great distress and despair, when they come to see me for a consultation, will actually be taking an antidepressant at the time.  It means that I have a great strategy to pursue that is unlikely to have been previously explored. (I used to use lamotrigine and Seroquel as my “aces in the hole” for people with really bad symptoms you had already tried many treatment approaches.  But now those tools have been “discovered”, which is good.  But it means there are fewer things for me to pull out when people with symptoms like yours show up in my office.  So I’m glad to have this “let’s try gradually removing the antidepressant” as an available strategy.  It’s a good thing at work so often!) 

You notice the word in that last paragraph:  “gradually”.  I think this is another crucial key.  People with symptoms like yours who tried to go quickly off their antidepressant will discover that they are getting worse. That merely serves to convince them that the antidepressant is essential.  However, in my experience at least, when people go off much more slowly, they are much more likely to do so successfully, and discover at the end of it all that they are at least no worse than they were, and often substantially better.  This is such a paradoxical approach – going so slowly, when things are so bad; and removing an antidepressant, when the person is already depressed – that I have written up a brief essay about it on my website: Antidepressant Withdrawal Can Last Months? 

Of course, you must not try doing this on your own. have to work closely with your psychiatrist so that she/he knows what is going on.  That means that she/he will have to buy into the idea.  Sometimes that is pretty tricky.  Mind you, this is just an idea, not a specific recommendation.  There could be very good reasons in your case why tapering off in antidepressant is not a good idea.  That’s why it is so important to work with your physician.   

I hope that some idea in all this proves to be useful to you.  Good luck with the process.
 

Dr. Phelps