Treatment/Medication Resistant Depression

[comaseason]

I thought I'd start a topic for those of us who have treatment resistant depression. I'll share a little bit that I've learned from my experiences....

What is treatment resistant depression? My psychiatrist gave me the following guidelines:

Has the treatment failed to work? This includes years of multiple (some doctors say at least 4) attempts on many different classes of medications. In some cases the diagnosis of TRD can be made as early as 8 weeks (if the treatment is aggressive and being closely monitored in a hospital or treatment facility type of setting).
Has treatment worked but not enough to bring back to baseline?
Have side effects of medication been difficult to manage/handle?

Treatment resistant depression is more common than doctors would lead you to believe. I have had several doctors that would drag me down a path to finding the "magic" combo of medications that would end my 18 month long major depressive episode. At one point I was on 7 medications at one time, which any doctor worth their salt will tell you - is no good, you can't judge the effectiveness of any drug when there are that many kids in the pool.

According to studies up to 30-40% of people do not respond to the first 2 attempts that medication treatments. Why does this happen? Doctors don't seem to have an answer. In many cases there is a long wait before treatment begins and that could be a factor. I had dysthymia and major depressive symptoms for 15 years before I attempted medical treatment. Evidence also suggests that people with especially severe depression are just simply harder to treat.

Once I was diagnosed with TRD I was given options, some not so attractive - but there are options. I opted for the least physically invasive, which is rigorous therapy (individual and group). I have had fairly good success with that and saw an ease of my symptoms so my depressive symptoms now rate on the high end of moderate, down from the high end of severe. But if I get worse again I will definitely choose one of the other options, such as TMS or ECT.

Talk to your doctor if you've been on the merry-go-round a while. Explore other options. Take your power back, you aren't at the whim of medications or any specific doctor. Ask questions - can you check my thyroid, my vitamin levels, my hormones? Get a 2nd unbiased opinion, unbiased is important, if your dr. works in a clinic go outside the clinic for your 2nd opinion - since difficult to treat patients are often reviewed in-house anyways. Make sure if you are taking medication, you are taking it as directed - if it is difficult to take as directed (i.e. multiple times of day, when symptoms are at their height and you forget, etc.) tell your doctor so that another alternative can be found. If possible find a doctor to review your case who's specialty is pharmacology. If you're not in therapy - get in it. A medication and therapy combo has been cited in numerous studies to always be the most effective.

TRD is a shitty diagnosis. But at least it's a diagnosis and there are options. I'm grateful that I don't sit around and wonder why the hell isn't any of this working for me?

[manuel_moe_g]

Great write-up, comaseason!

I am on medications (Effexor & Neurontin) that even me out, but still leave me with debilitating depression and anxiety.

I am "bridging the gap" with cognitive therapy.

Another good point, even if medication is successful initially, many will "poop out" over time.

Cognitive therapy should be stressed, in my opinion.

[Colonialpunk]

Hey,

I hope you don't mind if I post here, I have treatment resistant bipolar disorder, which is quite similar to treatment resistant depression (only I have manic highs and can't take specific antidepressants in the first place as they will trigger manic episodes).

A year ago I was in the midst of a 12 month long bout of depression which my psychiatrist tried like the dickens to get me out of. I tried 15 different medications, to no avail. He suggested ECT, but the idea made me extremely nervous so I waited it out and have been out of that episode of depression for about 8 months.

I have definitely decided that if an episode that intense comes on again, ECT is my next course of action. I find it comforting to know that I've made that decision while in a moderately stable place, instead of making it while in the middle of an episode.

For me the biggest help has been doing what I can to keep me from slipping into a deep episode when I'm not in one. Improved diet, exercise, social life, & sleep have been extremely helpful, as well as therapy.

[EliCash]

This may be a weird thing to bring up, but have your doctors ever suggested participating in studies that focus on treating TRD? I say this because I have noticed the interest in TRD spike recently, much of which is based around studies searching for effective ways of treating TRD.

[comaseason]

I have definitely decided that if an episode that intense comes on again, ECT is my next course of action. I find it comforting to know that I've made that decision while in a moderately stable place, instead of making it while in the middle of an episode.

For me the biggest help has been doing what I can to keep me from slipping into a deep episode when I'm not in one. Improved diet, exercise, social life, & sleep have been extremely helpful, as well as therapy.

I totally get how you feel about making the decision for ECT while in a more stable place. I think it's awesome to be able to weigh the benefits while in a stable (or as stable as it gets ) and then make a decision that's right for you. I know a lot of people have tried to talk me out of it and would get all disapproving and whatnot. I say fuck them. I'm glad to know that there are other people like me out there. I think it's just a decision that is a personal one, and at least for me I decided there's no way in hell I'm going back to the place I was in. I nearly died and I just don't think it's worth the risk to try and wait it out.

I'm so glad you mentioned diet, exercise, social stuff, and sleeping. I think that's really key to trying to get on top of it early. When I was in the hospital they called them "the Basics". Basics were: Food/Diet, Med/Vit, Sleep, Spirituality, Relaxation, Exercise, Journaling, and Affirmations. We would have to make daily plans for how we would improve each thing on the list.

Sleep was the key thing for most of us in treatment. We actually sat in hour long classes about it. I learned a lot of interesting things that I didn't know. Like stage 4 sleep is the only time that Seratonin is created in your brain, so if you don't get to stage 4 - like ever, then your brain never has a chance to make it. Also that if you drink alcohol, within I think it's 4 hours of sleeping, you never get to stage 4. We learned how to properly treat insomnia. It was very helpful. Just getting better sleep I noticed an improvement.

This may be a weird thing to bring up, but have your doctors ever suggested participating in studies that focus on treating TRD? I say this because I have noticed the interest in TRD spike recently, much of which is based around studies searching for effective ways of treating TRD.

As I'm currently not on any medication, I don't see a psychiatrist anymore - there's just no point in paying the money. I just see my therapists. If/when I get bad again, it's definitely something I would ask the doctor about. But at the moment I'm fairly stable, and my psychologist is pretty clued in to research that's being done and whatnot. I trust that if he saw something that was a good fit for me he would let me know about it. Odds are I probably wouldn't be a good candidate because I have PTSD, and they would probably be first trying out things on people with straight TRD and no other contributing factors.

[in_media_res]

I'm so glad you mentioned diet, exercise, social stuff, and sleeping. I think that's really key to trying to get on top of it early. When I was in the hospital they called them "the Basics". Basics were: Food/Diet, Med/Vit, Sleep, Spirituality, Relaxation, Exercise, Journaling, and Affirmations. We would have to make daily plans for how we would improve each thing on the list.

I agree, I believe this is exceptionally important in fighting off depression - and much of it's available to everyone, at least to some degree.

Almost two months ago, I fell into a deep, suicidal depression after my long-time therapist abandoned me. At this point, I refuse to use anti-depressants - they don't work for me and cause unacceptable side-effects. But I've focused a lot of attention on these activities (particularly exercise, journaling, and spirituality (including mindfulness meditation)). It's kept me going and has, I think, been useful in helping to get through the worst of the depression. The journaling and meditation has also been helpful in trying to restart therapy.

ECT was, and I suppose still is, an option. My psychiatrist was pushing it pretty hard, along with every other med in the book. I don't know that much about it, although I know of someone for whom it's supposedly worked well. But I think trying to decide while you're relatively stable seems sound.

Good luck to everyone.

[comaseason]

ECT was, and I suppose still is, an option. My psychiatrist was pushing it pretty hard, along with every other med in the book. I don't know that much about it, although I know of someone for whom it's supposedly worked well. But I think trying to decide while you're relatively stable seems sound.

I've known several people who have had really positive results from ECT. There's a lot of stigma on it as a treatment because of the way that it used to be performed, but there have been a lot of changes and advancements of how the treatment is administered. My first introduction to ECT was from a few documentaries about treatment of mental illness in the 60s. So I was pretty scared of it when it was presented as an option. But then it was explained to me and I'm not as afraid of perhaps someday having to make that decision.

I find it somewhat comforting to know that there is a last resort treatment available should I be in a dangerous place again.

I think it's smart to weigh side effects when deciding to choose a treatment. I'm glad you stood up for yourself, it takes a lot of strength to be able to do that when you're in a somewhat fragile place.

[BCZF]

For what its worth, I finished reading the latest Carrie Fischer book and her bouts with depression. She gets regular ECT treatments and she seems to have benefited a great deal from them. There is a risk of short term memory loss, but I believe this is a temporary condition. And she was as ill as they come, and for her to find relief from this, I think is an eye opener.

ECT is kind of a scary proposition, mostly from "Cookoos Nest" type of stigma, but it is, as I understand it, now very precisely controlled under sedation.

[comaseason]

There is a risk of short term memory loss, but I believe this is a temporary condition. And she was as ill as they come, and for her to find relief from this, I think is an eye opener.

I felt the same way when I read her story and met with people that had ECT done.

My doctors told me the short term memory loss is typically confined, if it occurs, to the hours/day surrounding the treatment.

[in_media_res]

My psychiatrist offered rather broader warnings - he indicated the possibility of past memory loss.

We discussed the matter extensively as an alternative to antidepressants.

In my case, I elected not to pursue it, at least at this point. Although this bout of depression has been severe, I've been able to more or less keep up my work. With ECT, I'd be unable to work 3 days a week for 4-6 weeks during treatment, and even if memory lost was constrained to time periods around treatment, I'm concerned it would end up trashing my productivity. Or what's left of it. I might be able to secure some sort of short term disability, but my work - and the work environment - don't seem as conducive to that, at least for mental illness.

I've subsequently read that in some studies, overall effectiveness is near placebo, and long- term effect can be elusive.

So I'm back to square zero. Or nearly so - I've tried to restart with another therapist. Given my recent experiences, I've been reluctant to truly engage, but I think we've started to engage. Working out helps. And meditation provides a channel for letting go, and forgiveness. I suspect it's going to take a long time, but if I make it I'll at least have learned some coping skills.

It's frustrating that medical treatments seem mired in such limited effectiveness and undesirable side effects.

For those who want to read more about the shortcomings of medications, I'd suggest "Anatomy of an Epidemic" by Robert Whitaker. http://robertwhitaker.org/robertwhitake ... demic.html