Q. I am a 50 year old female. I have no memory of ever feeling happy or contented with my life. I have been death-oriented (suicide wish) nearly all my life. I want to die but am committed to the well-being of my family members. My suicide would not be in their best interests. When I was a teen I overdosed a couple of times and hung myself once. (the extension cord broke) I was treated for depression through my teens, twenties and thirties. 

At age forty I was diagnosed with bipolar disorder. I have been on lithium for ten years. No antidepressant has been successful for the long term. All worked briefly. I have zero self-esteem, am 60 lbs. overweight and eating disordered. (I don't binge but do purge) I have GIRD, ( a bonus for the bulimia) and every day I pray to die. 

I trust no one, (except husband) and I am exhausted from living. I feel I have tasted and experienced as much of life as I care to. I am 99.9% negative. All medications left me feeling dull and confused. If I was bright enough to take myself out and have it appear to be accidental, I wouldn't be writing you for help. My heart and my spirit are broken. Any suggestions? I put in six years on the couch. I'm talked out.

 

  A. It must be painful having to feel so badly all the time. It made me sad to just read your synopsis. There are possibilities. It is very unusual for bipolars to have bulimia and chronic suicidality and the other maladies you talk about. You have a mood disorder, but I am not sure where bipolar comes from. The mood swings you likely have are affective instability, and part of the depression. Anyhow, if what you are doing is not working, and you keep doing the same, nothing will change. So, either you find an add on or new medication combination or change diagnoses and attack the problem differently.

One option is to get a second opinion. This is always a good way to go. There are plenty of good doctors out there, and maybe someone can help. As always, I recommend University based teaching programs for that second opinion. Not to detract from private practitioners at all, it is just that there tend to be more doctors that specialize in treatment refractory depressed patients at Universities.

Another option is to ask you current doctor about your diagnosis, and why he or she thinks you feel so poorly. It is not a matter of therapy. No one wants to feel bad. You do not need more therapy yet, you need corrective pharmacological management. The illness is like having torn knee ligaments. No amount of therapy will reconnect ligaments. You need a physical intervention, surgery, which is analogous to the taking of medications. Then you do therapy for the knee so it works well. In illnesses like yours, therapy is much better after things are corrected physically with the proper medications.

You may want to read the medication letters on borderline personality since the treatments for long-standing depression are almost identical in the majority of institutions and centers that treat chronic depression.