I have suffered with depression and fatigue for over 40 years. Is there anything that will help the 'flatness' and 'no motivation'? I cannot make myself do anything. I also sleep pretty much 18 hours out of 24.

Addressing any symptom begins with trying to diagnosis the cause. You may be wondering whether your symptoms are due to your mood disorder or could be caused by a general medical disorder.

Since your condition seems to be life-long, it’s not likely that you are suffering from a medication side effect, infection, or have an acute life threatening condition.  Simple blood tests and an EKG are usually sufficient to rule out the most relevant medical problems. Most people are not well served by endlessly pursuing expensive evaluations for rare conditions.

This brings us to the realm of psychiatry. There are three main possibilities to sort out: 1. Your treatment could be ineffective, 2. Your treatment could be partially effective, or 3. Your symptoms could be due to side effects of your treatment. In some cases the answer may seem obvious, but for most cases there is substantial uncertainty and management proceeds based on a working hypothesis.

Under hypotheses 1 and 2, you haven’t responded adequately to current Plan A and will be looking for a more effective Plan B. Before you move on to Plan B, however, it’s sensible to be sure you have given Plan A adequate time at a therapeutic dose before moving on to a higher dose of A or to new treatment B. Importantly, patients may find antidepressant medications work best when used in conjunction with lifestyle changes (e.g., regular exercise, a healthy sleep/wake cycle, and a healthy diet) and/or formal psychosocial treatments (e.g., Cognitive Behavior Therapy, Interpersonal Social Rhythm Therapy, or Family Focused Therapy).

Under hypothesis 3, you will be weighing the risks and benefits of management by subtraction, reducing the dose or eliminating the offending treatment. Management by subtraction (of ineffective medications) is a very attractive option, because it can often produce quick improvement, but reducing partially effective medication can lead to worsening depression. This risk may be managed by reducing the dose gradually in search of a level where the adverse effects resolve and the treatment remains effective.

Whichever management option you choose, routine measurement of your progress can be a helpful way to guide your care.  This can be as simple as keeping a daily mood chart or using a rating scale once a month.

About the Doc

About the Doc

Dr. Gary Sachs is Director of the Bipolar Research Program at Harvard University.

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