Medication resistant depression?

I have a 10 year Hx of depression.  I was placed on Prozac intially with decent results.  Since then I have been on and off of Prozac and therapy.  Several years ago severe Panic Attacks developed out of the blue. This was controlled with Xanax, Prozac and more recently Clonopin which greatly lessened the addictive problems of the Xanax.  Recently after complaining that the Prozac was no longer working for the depression, my psychiatrist Rx me Effexor.  Within a few months the panic attacks all but dissapeared!!  Kudos to the Effexor.  I assume this improvement is due to the norepiniphrine-serotonin combination vs. the serotonin reuptake adjustment only, with the Prozac.  However despite the mitigation of the panic attacks, the Effexor even at 300mg/day does not seem to have any effect on my depression/fatigue.  I ponder if I have become medication resistant.  I have not been in therapy for years, but will be shortly since I realize that medication combined with therapy is shown to be more effective than one or the other.  Any thoughts on what to do next?  My recent physical suggests normal thyroid and good health.  I often wonder if the thyroid could be the problem, perhaps the level was adequate at blood test time, but is hypo most of the time in reality.  Please help, I'm loosing hope here.  Any suggestions for more advanced blood work over the usual "physical" that one gets at an HMO office, that could suggest a biological/medical cause?  Would the addition of Wellbutrin help the depression?  I only take about 1-2mg/week prn of Clonopin at bedtime by the way.  Since my life is actually in good order, I don't see much reason for this consistent depression.  I truly believe it is biological in nature, but aside from the usual blood tests I don't know how to investigate this problem further.  Thank you for your generous time.
            Sincerely depressed EMT,
                     Brian
                  

[HFHS MD-JM]

Brian,

     It appears that you are already taking an important step to improve your depression by resuming psychotherapy.  You report depression/fatique as a problem even though your panic attacks are well controlled.  I wonder if you have other symptoms of depression or are just experiencing fatigue.  How has your appetite, sleep, concentration, ability to enjoy things been recently?  If there are also problems in these areas then perhaps a further increase in your Effexor vs changing/augmenting this with a different medication.  Wellbutrin is very helpful in treatment of mood problems but questionable in panic disorder.  Nevertheless, these are issues you and your psychiatrist/physician need to discuss.  Some of the more common medical issues to think about in regards to fatigue are anemia and sleep disorders in addition to thyroid status.  Thyroid status is normal on your testing.  Thyroid levels fluctuate over months not days.

     This information is intended for educational purposes only.  Please consult your personal physician for specific health concerns.

Sincerely,

HFHS MD-JM

Keywords: Depression, fatigue