CQ - I have not heard of Topamax™ (topiramate) being successfully used for anything, except as an augmenting agent for mood stabilizers in the treatment of bipolar disorder. It seems to help drugs like lithium, valproate (Depakene™), divalproex (Epival™ - CDN; Depakote™ - U.S.) carbamazepine (Tegretol™), and, in a few instances, lamotrigine (Lamictal™) work better.

This is, of course, aside from it's use as an augmenting agent (sometimes by itself) in epilepsy; and some cases as a weight loss agent (especially for Zyprexa™ - olanzapine - induced weight gain - but I find it is not as effective as the it's press states, in most instances). I have heard that it's clinical trials in the treatment of obesity have not been as successful as hoped. Still, about 20% of people who use it for Zyprexa-induced weight gain will lose some weight; but usually not all the weight they did gain from the Zyprexa. It is still much easier to keep the weight off when taking Zyprexa (through diligent diet control and exercise), than it is to try to get rid of the weight, once it has been gained. Weight gain with Zyprexa seems to palteau at about 8 monts. But I digress from our original topic.

I do believe that your doc is correct in saying that Topamax probably is not the right drug to use for unipolar depression, nor PTSD. I may be wrong in this, but I have not even seen any case reports where it has been tried in these conditions.

Perhaps some cognitive-behavioral therapy or some graded desensitiztion techniques may help you to deal with the PTSD and be able to help you live with your condition. I am definitely not an expert in these fields, and DocJohn may be able to add some insight.

Have you tried Effexor XR™ (venlafaxine) for the depression. It seems to be the "flavor-of-the-month" in depression therapy, and works in cases where other antidepressants don't. It has worked in my depression, where nothing else seemed to.

Augmentation of antidepressants with lithium does work in many cases of treatment-resistant unipolar depression. Therre is much literature to back this up. Sometimes the lithium side effects can be intolerable, though.

As a side note, sometimes PTSD and panic disorder are made worse in the initial 2 to 4 weeks of antidepressant therapy. I call these "start-up" side effects. If you can get through this initial month of "hell", the PTSD &/or panic symptoms do, in most cases, drop off sharply. The hard part is getting to this stage. The benzodiazepines like clonazepam (Rivotril™ - CDN; Klonopin™ - U.S.), or alprazolam (Xanax™) can sometimes ease the transition from start-up side effects to therapeutic effect. Usually the Xanax or Klonopin can be stopped once the antidepressant kicks in. Aside from Effexor XR, Paxil™ (paroxetine), with it's sedating antimuscarinic effects seem to be very effective in panic-like disorders (like PTSD). I always say that antidepressants should, if at all possible, be given a fair trial of at least 8 weeks; in depression with an obsessive component, trials should be at least 12, or better yet, 16 weeks; again, if possible. Remember, the worsening of panic-like and PTSD will probably increase for the first 2 to 4 weeks, but, in the long run, this can be a small price to pay.

Still, I do believe that psychotherapy is a must, along with meds, in most, if not all psychiatric disorders. Again, DocJohn can tell you which specific modality would probably be best in your situation.

Also, don't rule ECT out. It is the treatment of choice for depression in the old-old (>75 years) and in pregnant women. The memory loss is transient, and usually only affects memory around the time the procedure is done. ECT today is not of the "One Flew Over the Cuckoo's Nest" or "Snake Pit" variety. Hollywood has really ruined a great treatment by stigmatizing it.

Another new treament for depression involves seizure-inducing transmagnetic stimulation (sTMS). Where regular TMS is probably not going to live up to it's hype as an antidepressant treatment, sTMS may hold promise. I would let the researchers work the bugs out first. In principle sTMS should be able to focus directly on brain structures where scientists believe depression seems to be located (eg. probably the hypothalamus &/or pituitary), without affecting adjacent brain structures. The magnetic impulses of sTMS are not impeded by the skull, as ECT electrical currents are (the skull partially blocks and spreads out much of the electrical signal, thus affecting adjacent brain structures). The major problem with sTMS is getting enough magnetism to induce a seizure. This require the magnets to heat up far too much and burns the skin on the scalp. Once they overcome this problem, and run several successful clinical trials, this procedure may become a very viable treament for depression and bipolar disorder. Until then, let others be the guinea pigs (including rats and guinea pigs).

Sorry for the rambling. If there is anything that you would like me to clarify, I will be happy to try. Perhaps ask DocJohn for his opinions on this as well.

- Cam