'Nother med question -- Cam? T_MD? Larry? Breakthrough depression

I'm on Cymbalta -- which I'm out of right now -- 30mg; Wellbutrin XL 150mg; Provigil 100mg; dx Major Depression, Anorexia Nervosa, Anxiety Disorder NOS.

There are so many variables involved right now that I'm not sure which is most important, so I'll list them all as briefly as I can. Whatever combination of these variables is involved in my current depression, I wonder what the best option might be right now, in terms of changing meds? Any bits of wisdom you care to share are appreciated.

Variables:

Running out of Cymbalta -- although I'm not sure it's really doing much for me, so I'm least concerned with this.

Weight gain -- I've gained 35 pounds since November, and just in the past week or two it's been really horrible. I never realized just how much my self-image and self-esteem seem to be tied to my weight and shape. And no -- not getting any treatment related to this, because no one in this area will take on an adult patient with anorexia. (Although they'd be glad to see me if I started to purge, it seems, since they all treat adults with bulimia...)

New therapist -- after being totally shut down emotionally for a year or so, I'm opening up. That may actually have a lot to do with all this, although I'm betting it's the symbiosis between opening up emotionally and that I'm restricitng so much less. AN for me is all about emotional control, so eating more is associated with a lack of that control.

Practical problems, with marital issues involved: this part is the hardest to explain, but the very condensed version is that my husband NEVER does anything to show me that he finds me at all attractive. He will *say* it, when he thinks of it (usually when I'm crying about how hideous I am), but he never does anything like voluntarily hold me. Then there's the practical part: his car isn't running -- hasn't run for about two years now -- so we're sharing mine. This means that, if I want to leave the house, I have to play Taxi Driver for him -- at his convenience. Problem is, he doesn't work a regular schedule -- he goes to work when he's ready to go, so I can't plan. Unfortunately, he doesn't respond to my needs, so I can't consistently do things that I think would help me a lot, like getting to the Pilates class that's supposed to be part of my treatment plan, etc. (Hell, I can't even consistently get to doctor's appointments, unless he accidentally gets ready to go at the right time.) This, as you can imagine, just reinforces my sense of my own worth. Or, rather, utter and entire lack of worth.

So, lots of variables. Part of me says that it's the practical, behavioral things that have to change to remit this depression. Another part says that that ain't likely to happen -- since my husband's behavior is entirely outside my control, but his cooperation would be necessary to make those things happen -- so I better look to meds. And still another part says that it's OK to look to meds, because if they improved my depression, I might find ways to improve the practical side of things.

Anyway, I'm a bit hesitant to consider raising the Cymbalta, because at higher dosages I was entirely amotivated, very lethargic, my blood pressure went up, and I don't think it did anything for my depression. I also think that the lethargy contributed to the depression, by keeping me from doing things that might help me behaviorally.

I'm equally hesitant to raise the Wellbutrin, though, for the obvious reason: seizure risk. I know that the risk is low, and that the "no Wellbutrin for those with eating disorders" is really about bulimia, but I'm still concerned. On the other hand, adding Wellbutrin to Cymbalta lifted longstanding depression within two weeks, so I know it's doing something.

Raising the Provigil won't do anything except make me jittery. It doesn't improve the fatigue or lethargy.

Mind you, right now I feel as though the best thing I can do is to drop all the meds, except maybe the Provigil, and stop eating again, because when I am actively restricting, I have more energy, get more done, feel a hell of a lot better about myself, etc. In other words, I'm depressed, so if you give me your best advice, and I say, "Yes, but..." please forgive me. I know that's how I'm feeling, and I know I would want to slap me, but I figure you all probably understand...

Thanks!

You ask some very good questions about complex problems. Obviously it would take someone who knows you very well to give you a meaningful answer. I will say that frequently patients with long term problems often have very sudden changes in moods, and are sometimes quick to attribute it to the medication not working. For me the most useful strategy is not too look at symptoms on a day to day level but rather month to month. Anorexics do indeed have a 'bad reputation' with psychiatrists. Usually it is because these patients seem much more ambivalent about accepting help. People who are ambivalent often aren't reliable about keeping appointments, compliance with recommended treatment, etc. I don't know if this is your case, because I don't know you. Probably if you are involved with regular psychotherapy, and perhaps had regular primary care doctor appointments to monitor your health, a psychiatrist might feel more comfortable treating you (I don't know if you have these things or not). Unfortunately there are no quick fixes to anorexia, and whatever treatment you get will likely take a long time to pay off.

Thank you, T_MD. When I said that the specialists wouldn't see me, I meant psychologists, not psychiatrists. Or, at least, the psychiatrist whom I see will see me, and that's enough for me. (I like him, which is rather amazing after some of my past experiences. And I -- mostly -- trust him, which is much more amazing.)

And you're absolutely right -- I am very ambivalent about recovery. I do comply with meds, but have a hard time complying with the meal plan my nutritional counselor has made up for me. Of course, that's because anorexia has worked for me, sick as that is. (Well, it's also obvious, when you think about it: if it didn't have some benefit, we wouldn't continue doing it, right?) So there's the habituation because of the benefits to fight, as well as all the obvious things like shrunken stomachs, etc.

For what it's worth, I saw my psychiatrist today -- who was very concerned about his office staff not getting back to me last week while he was on vacation -- and we raised the Wellbutrin XL, so we'll see how that goes. He's also given me a prescription for Ambien, to try to break the insomnia cycle. (And warned me about the risks of being awake after taking it: told me a story about getting paged after he had taken it, and the consequences.... Another reason I like him: he will tell stories about his own experiences if they're relevant. My favorite involved drinking Chartreuse...)

Thank you again for checking in. I was wondering if I'd forgotten my deodorant or something, when no one responded...