Approaching the (possibly) Unapproachable Doctor

I am a 33 year old female diagnosed with major depression 7 years ago and ADD about 5 years ago. I’ve been on several Tricyclics, SSRIs, Cymbalta, Effexor, Wellbutrin, Tegretol, Abilify, Provigil, Klonapin, Synthoid(for slight underactive thyroid possibly contributing to depression),Yaz (for possible PMDD contributing to depression), and Concerta, plus more (many of these I’ve tried in combonations under my psychiatrist’s orders as well). I’ve never been on any MAOIs. I am currently taking 100 mg of Pristq, 50 mg of Vyvanse, and 100mg of Trazadone for sleep, as well as a multivitamin and a b-12 supplement. I was hospitalized in October 2008 as I’d decided that I wasn’t going to try and deal with my depression – I wasn’t going to live anymore. When I began taking Concerta about 5 years ago, it really seemed to help with both depression and ADD. However, it pooped out on me along with Cymbalta after awhile. For about two years now, I’ve been feeling emotionally numb along with depression and ADD. I no longer aspire about my future nor do I enjoy the things I use to. I’ve isolated myself from friends/family and any type of social functions, including church. I feel as though I’m slowly waisting away and my children suffer because of this. I read constantly about different medications and the effects (good or bad) they’ve had on others on your blog as well as other blogs. I’ve been doing research on the dexedrine lately and it seems that many individuals have had success with this drug for both ADD as well as depression. However, I can’t seem to encourage my psychiatrist to try it in my ‘cocktail’ to see if it will help. I’ve never abused or attempted to abuse any prescription or illegal drugs so I’m uncertain why my psychiatrist won’t try it as my depression is classified as atypical or treatment resistant at this point. He wants me to stay on this current ‘cocktail’ of meds until May 2009. If there are no changes, he’s going to refer me for ECT – which I’m not totally against because nothing else seems to be working. I’m just surprised he’d consider ECT prior to trying Dexedrine. I would never tell any professional how to do his/her work, but I should have some say so in my personal treatment options as long as they’re within good reason. What is the best way to approach my psychiatrist with my concerns without seeming as though I’m questioning his/her professional or knowledgable approach. Or worse, ruin any rapport we’ve established thus far? I thought your suggestion to the gentleman that adding a small dose of dexedrine to enhance his Vyvanse could be beneficial was interesting. I would like for my psychiatrist to consider this as I just want my passion for living, dreaming, exploring and loving back. Any advice you can give me will be greatly respected and appreciated. P.S. Have you prescribed the EMSAM patch? If so, what has been your patients’ overall experiences with it?

Sorry for the long comment above, but I thought it very clearly highlights a dilemma faced by many.  How do you contribute to your health care decisions without insulting your health care giver.  This is just as true in other branches of medicine as it is in Psychiatry.  People are more inclined, however, to hand over their back surgery to their orthopedic surgeon without a lot of questioning than they are to hand over the management of their mood to a shrink.  Not that your mood is any less complicated than your back is . . . but their is something so . . . personal . . . about your mood and emotions that people do not want to let go of the control of them.  And, in my humble opinion, you should NOT just hand the decision process over to anyone.  Part of getting better from this depression thing involves taking control over your life.  Not sitting around waiting for it to get better.  That includes having some control over the medication management of your illness.  

The entry above has multiple questions to it, but their are overriding themes.  Clearly, many medications have been tried with partial or incomplete response.  The order, combination, etc of meds is not highlighted, so that no conclusions can be drawn from the entry EXCEPT that you are with a psychiatrist who is willing to try different things and experiment.  That is good.  As annoying as the “wait till May” thing might be, it might be good clinical judgement.  Giving a medication regimen a chance to work is imperative, especially if you have failed multiple other trials.  That might be what he is doing here.  Is it time for ECT?  Not if you are willing to take an MAOI.  I have no experience with the EMSAM patch, mostly because my patients with treatment resistant depression have no interest in the MAOI diet (quite restrictive, but doable).  

I would also suggest that you be straight forward with your psychiatrist about this.  Praise him for his efforts and for the rapport that you have with him.  If you want ECT to be the LAST thing on the to-do list, tell him that.  There clearly are other options to be tried.  Either with his knowledge or without his knowledge, I think it is time to get a second opinion.(  (I personally love it when difficult cases go for second opinions–I don’t claim to have all the answers).  Find someone else in your area that does medication management (local hospitals or university centers are often a good place to look) and get an appointment to meet with them for one or two visits.  You may need to pay out of pocket for it but the insights into your illness might be worth the money, if only to know that your current psychiatrist is covering all the bases.  Make sure you take with you a COMPLETE chronological listing of the medications and combinations of medications you have taken over time.  If you are not sure of dates, you can often get that information from your pharmacy.

Good luck and HANG IN THERE.  Sometimes it takes a long time to find the right combinations of medicines and circumstances that make you feel better.  

–Dan Hartman, MD

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