Expert: Jurriaan Plesman, Nutritional Psychotherapist - 2/27/2008

Question
Hi Jurriaan,

I'm writing to you as I'm very interested in your experience with unipolar depressed patients who may have had very brief manic episodes when on different SSRIs. I know this is a long email, but I hope you can take the time to read it as I've done a lot of research and I'm still at a loss as to whether I am unipolar depressed (which I think I am) or Bipolar. I believe in order for you to provide feedback, you probably need to know my history with psychotropic drugs. I was diagnosed in Sept 2004 in a mental hospital with Bipolar Disorder after a serious suicide attempt (while in a very deep depression). The doctor's basis for the diagnosis seemed to be the seriousness of the suicide attempt, the fact that I spoke fast (which my whole family does and some of my friends too, however I doubt they are ALL bipolar), and that I had a father who had committed suicide (however he was definitely diagnosed as depressed not manic depressive). I can you that I've never in my 47 years shown any signs of hypomanic or manic episodes (if anything I'm the opposite, quite cautious and methodical), except after taking an antipressant. I had two (what might be called hypomanic) episodes after taking Effexor and Cymbalta for a few weeks (at separate times). Each episode lasted only  6 to 12 hours. The episode on Effexor consisted of me not sleeping at all one night (and having strange dreams) and then feeling convinced that my depression and anxiety were gone and the medication was working.  When I got up the next morning I called several people who knew about my depression to tell them how excited I was to be so much better. I don't think I was acting "crazy" but I definitely was not myself and people who knew me well could tell. The feelings of well being, however, only lasted perhaps 12 hours and then I was depressed again.  Prior to the Effexor, six months earlier in April 2004, I was on put on my first antidepressant (Zoloft) because of a breakdown I had (living under extreme stress and dealing with a traumatic death of a relative) that caused anxiety and depression (it was the first time in my whole life I had depression). While the Zoloft didn't help, it did not trigger a manic episode although I think it made me even more anxoius.

My suicide attempt occured after I'd been on Effexor for about two months or so (and about six weeks after the hypomanic episode. Effexor only seemed to cause my anxiety and depression to worsen and produced extreme side effects (strange episodes which almost seemed like seizures, extreme weight loss and agitation, paranoia and the 12 hour hypomania episode I referenced above).  At the hospital, rather than putting me back on Effexor, I was put on Lamictal, Abilify, Remeron and Klonipin because of the Bipolar diagnosis. After a couple of months on the new medications (on medical leave from work), I was incredibly concerned that I had to get back to work. While I felt like the depression had somewhat lessened, I was still timid and very unsure of myself (prior to the breakdown I was always confident and very adept at my job-somewhat of an expert in my area). While they gave me a job of less responsibility than before, I felt incapable and had to pretend I could manage it. Needless to say, the supposed recovery was not complete and I began to deteriorate again quickly (more anxiety and depression). Within a couple of months I felt suicidal again as I thought I would never feel like myself for the rest of my life. I was terrified I'd never be able to work in my field. It seemed to my friends that the Remeron was making me more depressed.

At this point, I was put on Cymbalta and not only did it not cure my depression, it was so stimulating for me that I was very agitated the whole time. While I was on it I paced constantly, sometimes for hours. Again I couldn't work but was afraid to go on leave so I worked intermittently between pacing. This went on for several weeks. While pacing I would ruminate about how all the bad decisions I thought I had made and what an awful person I had been (where this came from I don't know). To counteract the ruminating, my psychiatrist gave me more Abilify which still didn't seem to work. Needless to say, after about three weeks or so I did have another hypomanic type episode although it was more like paranoia. Again I went without sleep one night due to worry and woke up thinking I was going to be fired for not working (afterall I was barely working during the pacing period). Rather than be fired (and suffer the humiliation of people finding out I couldn't do my job), I decided I would quit that day. When I told my boss, he was totally perplexed as he thought everything was going fine. His perception was the result of my having had a reputation of being so competent and the fact I was working on a project on my own. At any rate, he kept quizzing me as to whether I was sure I wanted to quit (I didn't sound right to him and he remembered I had also mentioned going out on leave again a week or so before). At any rate, I was in a panic and changed my mind and told him that I actually wanted to go out on leave instead. When I reached my doctor and told her I urgently had to have a medical leave confirmed she new there was something wrong. At that point I lost it and started to yell at her somewhat incoherently and admitted I had had suicidal thoughts again a few months back. Needless to say I ended up in a psychiatric hospital that night and for three days while they took me off the Cymbalta.

Due to what seemed to be an intolerance of SSRIs, I was not given any antidepressants but was left on just the Lamictal, Abilify and Klonopin. After three weeks on leave, I felt much better and was able to resume work and be productive. While I felt more like myself than I had in a long time, I still did not have the confidence I had had before (i.e. I was not fully back to myself) my breakdown, but I could once again enjoy myself and be productive (albeit not to the same degree). I was functioning for about 17 months and then the depression and anxiety came back again. Months went by and my doctor kept adjusting my meds (eventually taking me off Abilify as it didn't seem to work either).  Nothing seemed to help (again I went out on leave as I could not concentrate on work).  My doctor then decided to try another antidepressant on me, Celexa, which had no effect, and added the Buspar too. I was now on four medictations (Lamictal, Klonopin, Buspar, and Celexa). My friends at the support group I was in thought I seemed overmedicated. My doctor now thought that antidepressant would not work for me and recommended ECT of which I vehemently declined. Instead I found a new psychiatrist who then added only 100 mg of Wellbutrin which has been a "Godsend". He also weaned me off of all the other medications except Lamictal (of which he took me down to 200 mg from 300 mg). At any rate, for the first time since I had the breakdown in the Spring of 2004 I feel like my old self again.

The point of this very long history is that while I realize I'm sensitve to antidepressants, not all of them triggered hypomania (even though some of them were SSRIs). Since Wellbutrin is of a unique class of antidepressants, isn't it possible that my chemical imbalance required the needed medications in Wellbutrin as opposed to those in SSRIs? Couldn't I be unipolar depressed and still have isolated  

Answer
Dear Valerie,

I have been reading your story and frankly I don't know if i can be of any help. As a nutritional psychologists I do not believe in treating mood disorders with medications as a first step. I don't know to  what extent drugs have aggravated your symptoms. This can only be assessed  by a therapist who has a face-to-face relationship with you.

I don't know whether you have explored the possibility that hypoglycemia may play a role. Please check yourself with the

The Nutrition-Behavior Inventory Questionnaire (NBI) at:
http://www.hypoglycemia.asn.au/articles/nutrition-behavior_inventory.html

and/or the

The Hypo Quizz at:
http://www.hypoglycemia.org/hypo_test.asp

If you score high at least hypoglycemia may play a role as well. Please have a look at various articles at our web site,  to give you some clues, such as:

Depression is a Nutritional Disorder at:
http://www.hypoglycemia.asn.au/articles/depression_disorder.html

Nutritional Aspects of Schizophrenia at:
http://curezone.com/upload/Newsletter/Hypoglycemic_He/HYPONL2001_06.pdf
and go to page 7 of Newsletter.

If you want to pursue a more holistic approach I suggest thyat you ask your doctor to be referred to an orthomolecular psychiatrist or Nutritional Doctor or a Clinical Nutritionist, for proper assessment and treatment.

I hope I have been of some help.

_______________________________________________
Jurriaan Plesman BA (Psych) Post Grad Dip Clin Nutr
Editor of
The Hypoglycemic Health Association of Australia.
www.hypoglycemia.asn.au
Author of "Getting off the Hook"
Freely available at Google Book Search