Expert: Ivan Goldberg, M.D. - 3/15/2010

Question
QUESTION: Dear Doctor,
I have bipolar disorder and around six months ago, I had a severe depressive episode in spite of being on medication. As a rule, I suffer from very low energy unless I am fully well or hypomanic.
This particular depressive episode started with full blown mood symptoms and fatigue. However the mood symptoms minimized suddenly and I was left with fatigue so crippling that I was bedridden and could barely lift my head.
Although my psychiatrist initially believed it was severe depression causing the fatigue, after experimenting with some medication (including Parnate) he started to feel that the exhaustion was way too excessive and could not be explained by a psychiatric condition. He ordered some physical tests all of which came out normal (including a sleep study). All the physicians and specialists I saw couldn’t find anything and they told me to ‘go back to my psychiatrist’.
Till date my psychiatrist who has been treating me for 10 years maintains that this fatigue is not part of the depression and that he cannot explain it. As an emergency measure, I am now surviving on stimulating drugs. I take 400mg Provigil, 40mg Ritalin and 450mg Wellbutrin yet I am just about managing to get out of bed and spend the day surfing the net at best. I am also on Lamictal 200mg and Prozac 20mg. Prozac is the only antidepressant that does not sedate me.
Do you believe that this level of fatigue could be caused by bipolar depression alone? If so how it is that such high levels of stimulants are barely working- can I be that treatment resistant? Are there any avenues left to treat the depression/ fatigue. For the record in the past 10mg of Ritalin would have made me hyper- today 40mg is just about propping me up.
Is it worth pursuing the physical angle despite what the physicians have said? They may be missing something. What would you suggest I do.

Thank you.

Regards,
Divya

ANSWER: Hi Divya . . .

Anergic depression, i.e., depression accompanied by profound fatigue has been reported for many years. When I see such a patient I first have them gone over by an excellent specialist in internal medicine and if nothing turns up there I proceed as if the fatigue is part of the depressive process. More often than not, anergic depression is seen in people with some form of bipolar disorder.

My treatment of people with aneregic depression involves the combination of lithium and Parnate. Often the parnate has to be dosed at amounts well above the 60 mg/day that is conventionally considered the maximum dose. If lithium + Parnate at the maximum tolerated dose is not successful in resolving the depression I VERY gradually add dextroamphetamine.

The two links below may be of some interest. The first is to the abstract of a study of the effectiveness of Parnate in treating individuals with anergic depression. The second is about the usefulness of the Parnate-dextroamphetamine combination.

http://www.biopsychiatry.com/trandep.htm

http://www.ncbi.nlm.nih.gov/pubmed/15554766

If your psychiatrist is unwilling to use this approach you might seek a second opinion from one of the expert psychiatrists listed at:
http://www.psycom.net/depression.central.psychiatrists.html

Best regards . . .

Ivan
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---------- FOLLOW-UP ----------

QUESTION: Thank you for the reply, doctor.
I tried Parnate during this period and went up to 40mg. I lasted 1 month as it really sedated me and gave me terrible hypotension. I was taking 200mg Provigil but still it was knocking me out.
Perhaps dextroamphetamine would be better but unfortunately it is banned in my country.
Is there anything else I can try? Is there a way of managing the hypotension and sedation of Parnate?
Thank you so much
Divya

ANSWER: Hi . . .

I don't understand. You list your country as the United States and dextroamphetamine is legal in all 50 states.

Best regards . . .

Ivan
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---------- FOLLOW-UP ----------

QUESTION: Sorry for the confusion.
I have not listed my country as USA. The website is probably picking up my I.P address and at the moment I am in NYC. But I live in India where the only legal stimulant is Ritalin.
Thanks again and sorry for the misunderstanding.
Sincerely,
Divya

Answer
Hi, again . . .

Now I understand.

The combination of Parnate + methylphenidate is certainly an acceptable treatment for people with anergic depression. If I suffered from such depression, and it was interfering in my life in a major way, I'd want 8-12 weeks of drug therapy and I'd then want to be treated with electroconvulsive therapy.

Best regards . . .

Ivan
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