Goals in treatment resistant depression

[medstudent234]

I'm a resident, and I have multiple patients on my panel with very severe treatment resistant depression. They have had adequate trials of multiple medications in each antidepressant class, as well as augmentation with just about everything (antipsychotics, lithium, mood stabilizers, stimulants, thyroid replacement) and have been in therapy for years. Several of these pts have also had ECT and ketamine with minimal results. They have been coming to our clinic for years and years and are predictably dysphoric at every visit.

Do I keep trying the very few things they haven't done in a heroic effort, or at some point should I just essentially give up and push a more acceptance of depression as a chronic illness approach and try to help them maximize the good parts of their life? I'm kinda of leaning toward the latter, but as their medication provider I'm not totally sure how I would approach this due to my role in their care? Thanks!

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[WisNeuro]

ACT with some behavioral activation thrown in may show some minimal improvements, tough to say what's been tried with people.

 

[Sushirolls]

Reconsider / review the diagnosis. Is this really MDD Recurrent, or Axis II? Persistent depressive disorder?
*Consider getting an MMPI to explore more of the Axis II.
*Explore if bad social/family/marital dynamics?
*Consider getting a UDS and broad spectrum testing to see if any substance use disorders.
*Review secondary gain, i.e. patient wants to be on disability and they are making sure they will keep it.

Get the records of the ECT, and see if there is room for optimization in parameters and a retrial. i.e. 1ms PW BT or 1ms PW BF.

Has TMS been tried?

At least document / discuss VNS.

Consider a residential program for depression, which may focus on DBT. I think there are some in Arizona.

Look into a CAM type treatment like Heart Centered Hypnotherapy.

 

[Crayola227]

I read something that suggested on an evolutionary level, if you consider group evolution (which I know is highly controversial), that depression and suicide is parallel to apoptosis.

Now, this theory went on to discuss how cells receive signals from other cells about whether or not they are "needed" or they should self destruct. How for the most part, in absence of signal, the default is basically apoptosis.

We know how socially connected people are, is a huge predictive/protective? factor for depression and suicide.

Maybe it's only natural that via exogenous or endogenous signals, these people feel this way. Maybe they feel like a burden, unneeded, unnecessary, unconnected, because in some ways they actually are to the social organism, from a sort of evolutionary group perspective, or there's reason for them to think so. Maybe it is time for them to go.

OK, so if I'm not being fatalistic, I end up thinking for people where manipulating endogenous signals (meds we give them to counteract that) are not working, treatment will centre around reasons for them to stay on the planet. Chiefly social connections.

That might not even do it.

Anyway, I think for some of these people that can't be brought out of the funk, there might be a perfectly sound scientific reason for it, in that the tendency to depression and self destruction is in fact built into the brain, and under certain conditions is triggered, just as it is in apoptosis.

I think the chief approach would be to maximize the connection they may feel to society. Easier said than done.

Otherwise, maybe the switch is flipped and that's just how it is, and it's about trying to help a wounded animal or damaged cell continue to live. Sometimes it seems like all we can do is help people stay on the planet.

 

[Crayola227]

I agree with the above. One of the best ways to feel immediately better is to quit doing drugs and improving social dynamics.

 

[WisNeuro]

I agree with the above. One of the best ways to feel immediately better is to quit doing drugs and improving social dynamics.

Well, actually the drugs work pretty well for the immediately feeling better part. It's just those pesky long term effects of most of em

 

[wolfvgang22]

I read something that suggested on an evolutionary level, if you consider group evolution (which I know is highly controversial), that depression and suicide is parallel to apoptosis.

Now, this theory went on to discuss how cells receive signals from other cells about whether or not they are "needed" or they should self destruct. How for the most part, in absence of signal, the default is basically apoptosis.

We know how socially connected people are, is a huge predictive/protective? factor for depression and suicide.

Maybe it's only natural that via exogenous or endogenous signals, these people feel this way. Maybe they feel like a burden, unneeded, unnecessary, unconnected, because in some ways they actually are to the social organism, from a sort of evolutionary group perspective, or there's reason for them to think so. Maybe it is time for them to go.

OK, so if I'm not being fatalistic, I end up thinking for people where manipulating endogenous signals (meds we give them to counteract that) are not working, treatment will centre around reasons for them to stay on the planet. Chiefly social connections.

That might not even do it.

Anyway, I think for some of these people that can't be brought out of the funk, there might be a perfectly sound scientific reason for it, in that the tendency to depression and self destruction is in fact built into the brain, and under certain conditions is triggered, just as it is in apoptosis.

I think the chief approach would be to maximize the connection they may feel to society. Easier said than done.

Otherwise, maybe the switch is flipped and that's just how it is, and it's about trying to help a wounded animal or damaged cell continue to live. Sometimes it seems like all we can do is help people stay on the planet.

Heresy! How dare you, sir!

 

[NickNaylor]

Rethink the diagnosis, look for medical causes, consider an atypical presentation of another psychiatric disorder.

 

[PsyDr]

I read something that suggested on an evolutionary level, if you consider group evolution (which I know is highly controversial), that depression and suicide is parallel to apoptosis.

Now, this theory went on to discuss how cells receive signals from other cells about whether or not they are "needed" or they should self destruct. How for the most part, in absence of signal, the default is basically apoptosis.

We know how socially connected people are, is a huge predictive/protective? factor for depression and suicide.

Maybe it's only natural that via exogenous or endogenous signals, these people feel this way. Maybe they feel like a burden, unneeded, unnecessary, unconnected, because in some ways they actually are to the social organism, from a sort of evolutionary group perspective, or there's reason for them to think so. Maybe it is time for them to go.

OK, so if I'm not being fatalistic, I end up thinking for people where manipulating endogenous signals (meds we give them to counteract that) are not working, treatment will centre around reasons for them to stay on the planet. Chiefly social connections.

That might not even do it.

Anyway, I think for some of these people that can't be brought out of the funk, there might be a perfectly sound scientific reason for it, in that the tendency to depression and self destruction is in fact built into the brain, and under certain conditions is triggered, just as it is in apoptosis.

I think the chief approach would be to maximize the connection they may feel to society. Easier said than done.

Otherwise, maybe the switch is flipped and that's just how it is, and it's about trying to help a wounded animal or damaged cell continue to live. Sometimes it seems like all we can do is help people stay on the planet.

That’s the altruistic suicide theory postulated by de constanza. There’s also the bargaining hypothesis where such actions or complaints are a method to elicit help. Then there’s one where it enhances mate return/avoidance of infidelity/abandonment. There’s also the parasite hypothesis.

 

[LadyHalcyon]

I think this would be a good case to do some testing, maybe even an MCMI. Not so much for diagnostic reasons, but for treatment purposes. Sometimes I see patients are ambivalent about getting better because they think the only way they can get their emotional needs met is by being depressed. It's the whole "I need to be sad so people will pay attention and ask what's wrong."

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[clausewitz2]

There is a high chance with this sort of depression that there is also some element of personality functioning, substance use, or medical comorbidity that is playing a role in sustaining it. Agree with @WisNeuro about ACT; RO-DBT is also specifically designed with these people (and others) in mind, at least if this person has an agenda of emotional control. Would also be helpful to know which meds beyond "multiple in each class"; important to make sure you have drilled down into exact details about how doses, duration, etc. If they are on the older side also look at possible cognitive issues.

If they have been in therapy for years without any improvement in any of these symptoms I suspect that they have only been receiving a kind of vague, eclectic supportive therapy. That is fine for some things but real evidence-based, change-inducing therapy is not structured in that way. most resident clinics have a hard time holding on to good therapists, though, since their business model is often about hiring new grads and chewing them up as fast as possible until they burn out and move elsewhere, so it is unfortunately what the system tends to provide.

To answer your original question, though, you probably should be at least broaching the topic of "what do you want your life to look like if you always feel this way?"

 

[SourceOfDenial]

Psilocybin? Only slightly kidding.

So much of our language is rooted in the patient failing. Just the phrase, treatment resistant implies its the patient's doing, not the fact that we havent offered gold standard therapies, or medications, or as a field still fail to have relatively effective pharmacologic treatment options. My approach is typically one of strengths based versus illness. Maybe start framing the sessions such that 'wow, you've had this for so long but have still managed to do xyz...lets talk more about that'. Maybe some resource installation work. Agree with ACT as an option, but for patients who have depression and have been run through the gamut, it sometimes seems like something manualized isn't the best approach. If it could have been treated with a 12 week burst of sessions, it probably would have already been done. I'm usually relying more heavily on integrative or eclectic therapy for these patients. Also setting small small small milestones to guide progress and build hope.

I've had several patients with TRD who responded with MAOi. Also, for the chronic dysphoric/depressed patient I often wonder if the meds are keeping them from getting worse, or if the meds are worsening their depression. Scaling back on meds is a worthwhile discussion.

If the patient is in a resident clinic I'd offer several sessions to start a new. Take a full history from scratch, reformulate the case, discuss with supervisors. Close and careful attention paid to previous medication trials, talking with a pharmacist to help get as full a list of previously tried meds. Also, I think in residency the impact of trauma is greatly overlooked and not taught all that well. Is depression really the diagnosis or is the patient depressed because they have complex childhood trauma that is now 20/30/40 years in the past.

All of these are approaches that cant be done in a short block in a resident clinic. I'm also in the mindset that patients with TRD shouldnt be in a resident clinic. If you a PGY2 surgical resident your first case wouldnt be a whipple.