“I don’t know why I do this.” I don’t have anything to be sad
about. I just get upset sometimes for no reason. My daughter
thinks I’m depressed, but I don’t think it’s that bad. I do have a
lot of nervous energy, and sometimes I don’t sleep too well.”Carol is what we in the trade call a “smiling depressive.” Her cheer-
fulness is maintained by sheer nervous energy. She must always swim to
keep from sinking beneath the weight of her sorrow. Carol is fidgety and
flustered, but doesn’t fit the pattern of an anxiety disorder because sadness
rather than fear is her dominant emotion. Her sleeping problems—early
waking rather than difficulty falling asleep—suggest depression as well.
Carol gets up around three A.M. and does housework.
It’s hard to know in advance what kind of medication might work
best for an agitated depressive like Carol. Obviously, one that might
increase her arousal would be less suitable, so a tricyclic, which is more
sedating, seems a better choice than an SSRI. Her doctor prescribed
Amitriptyline, an older tricyclic that is verysedating. For a few days it
knocked her out. She slept most of the time. When she was awake, she’d
cry easily and often, as if the medication had slowed her down enough for
her depression to catch up. The antidepressant effect was still about a week
away when Carol stopped taking the Amitriptyline. She didn’t mention it
because she didn’t want anybody to worry.
A day later, Carol woke up cured, or so it seemed. She had energy
again, and she was cheerful and talkative. She’d make little jokes, and
sometimes would laugh at nothing. She became interested in genealogy,
and began spending hours on the phone with distant relatives. For a couple
of nights she was so wrapped up in her family tree project that she never
even went to bed.
In people whose depression is a manifestation of bipolar disorder,
antidepressant medication can sometimes precipitate a hypomanic
episode, like Carol’s. In her case, there was no predicting this effect
because nothing similar had ever happened to her before. Her genealogic
research did seem to show that there were a lot of alcoholics in her family
tree, and a few suicides. Both are more common in bipolar families.
Carol’s husband brought her to see a psychiatrist, who at first calmed
her with lithium, and eventually stabilized her on Serzone and a low dose
of Neurontin, an anticonvulsant sometimes used to prevent manic
Explosions into Sadness ❧ 165