Thanks, I prefer Seroquel XR as well. With IR I can't sleep, at least not after the first few hours. Unfortunately anti-depressants are a no-go for me because I've had a lot of mixed features coming and going in this episode.

Fatigue and low energy are definitely major issues for me, but then so is insomnia. The insomnia is really terrible -- I can't sleep for more than two hours a night if I don't take something sedating. I was on lorazepam for a while but obviously I can't use that forever. I've managed to stop the benzos and that wasn't easy, so I'd rather not start them again. That means something like Seroquel is necessary for sleep until this episode ends.

Bupropion is still an option, but I'm kind of afraid that any stimulant will make my insomnia worse. From what I've read it's also not that well-proven as an anti-depressant, but it could be worth a shot regardless. Like you said I could also try another anti-psychotic. I chose Seroquel because it had a lower risk of weight-gain than olanzapine. So far I haven't had significant weight-gain, but I do get tachycardia from Seroquel.

An added issue is that I appear to be a slow metabolizer of meds. I've noticed that very clearly with Seroquel. It doesn't get my mood stable, but instead it induces a sort of cyclical pattern, where I have to dial the dose back every two-three weeks because otherwise the side-effects build up. When I dial it back, my mood plummets to severe depression, and then it takes about 1 1/2 weeks to get back to moderate depression again. If I continue too long, it starts to induce mixed features, including lots of irritability and not sleeping.

Most of the bipolar meds are apparently metabolized by enzymes from the same family that metabolizes Seroquel, so I'm likely to have similar issues with other meds. That's another reason why I'm still really hoping for ECT. I think I should be good with lamotrigine if I can get on that as a maintenance treatment, because it's metabolized by a different enzyme. I didn't notice any side-effects from lamotrigine when I was on it.

I'm definitely also looking into non-medicinal options. Part of the problem is that most of the time the depression is too severe to be able to really work on things with my therapist. My therapist thinks (and I agree) that I have to break out of the worst of this cycle somehow just to enable me to do that, making it kind of a chicken and egg problem. I'm trying things regardless, but when my mood falls back to severe depression it's like all the progress I thought I made goes out the window.