The challenge of managing chronically depressed patients

[thelastpsych]

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I have a few patients, usually females in their 40s or 50s, whom I inherited from past psychiatrists with a history of persistant and VERY impactful depressive symptoms (HAMD usually >30), with chronic suicidal ideation and almost no functionality in the real world.
The way I'm trying to approach these cases is:
1) Review the diagnosis, looking for secondary causes that may have been missed, and other psychiatric diagnosis such as personality disorders, OCD, PTSD, etc...no luck thus far, although a lot of these patients would definately fit in the "depressive personality" diagnosis some older psychatrists would use;
2) Try different and off-label approach: these patients have usually been tested on at least 2-3 SSRIs in max doses, with lithium/low dose-antipsychotics augmentation, with no benefitial result. I'm dealing with a population that does not have access to neuromodulation/ECT or even ketamine, so my therapeutic arsenal is already limited,
3) Try to engage these patients in behavioral activating activities, exercises, psychotherapy, group activities, OT, even meditation groups. Have had very little success as well - they don't want to go. They just come get their pills, usually haven't changed anything in their daily routines since the last appointment and complain about the same problems as always.

I try to have a more nuanced perspective nowadays, such as incentivizing and keeping record of small gains, and trying not to work more than the patient. But I keep feeling like I am missing something, I don't know. So, how do you usually approach these patients in the clinical interview to engage them more? What other resources could I use?

Thanks in advance!

 

[sloh]

Sounds like a lot of women after 30 yo lol

 

[comp1]

Can you give us more details on how they don't have access to ECT? ECT is certainly limited (particularly on the West Coast) and it can be extraordinarily difficult to arrange in terms of travel and other issues, but if you have a relatively large panel of these particular patients...I'm not sure what else you can do. It might be worth it to direct your energy towards increasing that access as opposed to pounding your head against a wall.

 

[thelastpsych]

Can you give us more details on how they don't have access to ECT? ECT is certainly limited (particularly on the West Coast) and it can be extraordinarily difficult to arrange in terms of travel and other issues, but if you have a relatively large panel of these particular patients...I'm not sure what else you can do. It might be worth it to direct your energy towards increasing that access as opposed to pounding your head against a wall.

I don't practice in the US lol english isn't even my mother tongue, so apologies for spelling/syntax errors

 

[clausewitz2]

I have a few patients, usually females in their 40s or 50s, whom I inherited from past psychiatrists with a history of persistant and VERY impactful depressive symptoms (HAMD usually >30), with chronic suicidal ideation and almost no functionality in the real world.
The way I'm trying to approach these cases is:
1) Review the diagnosis, looking for secondary causes that may have been missed, and other psychiatric diagnosis such as personality disorders, OCD, PTSD, etc...no luck thus far, although a lot of these patients would definately fit in the "depressive personality" diagnosis some older psychatrists would use;
2) Try different and off-label approach: these patients have usually been tested on at least 2-3 SSRIs in max doses, with lithium/low dose-antipsychotics augmentation, with no benefitial result. I'm dealing with a population that does not have access to neuromodulation/ECT or even ketamine, so my therapeutic arsenal is already limited,
3) Try to engage these patients in behavioral activating activities, exercises, psychotherapy, group activities, OT, even meditation groups. Have had very little success as well - they don't want to go. They just come get their pills, usually haven't changed anything in their daily routines since the last appointment and complain about the same problems as always.

I try to have a more nuanced perspective nowadays, such as incentivizing and keeping record of small gains, and trying not to work more than the patient. But I keep feeling like I am missing something, I don't know. So, how do you usually approach these patients in the clinical interview to engage them more? What other resources could I use?

Thanks in advance!

There's a lot going on here and I think the personality disorder piece is crucial here but I am struck by your description of having exhausted therapeutic options. Where are the TCAs, MAOIs, thyroid hormone, dopamine agonists, etc?

EDIT: if you are able to provide therapeutic interventions yourself, you may want to take a look at CBASP, it was developed specifically for these people. It is not a small commitment, however.

 

[nexus73]

3) Try to engage these patients in behavioral activating activities, exercises, psychotherapy, group activities, OT, even meditation groups. Have had very little success as well - they don't want to go. They just come get their pills, usually haven't changed anything in their daily routines since the last appointment and complain about the same problems as always.

I try to have a more nuanced perspective nowadays, such as incentivizing and keeping record of small gains, and trying not to work more than the patient. But I keep feeling like I am missing something, I don't know. So, how do you usually approach these patients in the clinical interview to engage them more? What other resources could I use?

Thanks in advance!

This bolded section is certainly familiar to me. I think after a while having a frank conversation with the patient can be helpful to both of you. Discussing that meds have limitations and all of the non pharmaceutical treatments you've recommended are much more likely to be beneficial than meds this point. If appointments involve the patient just unloading life difficulties that have occurred over the last month, maybe stretching follow-ups out to 90 days and letting them know the appointments will be focused on meds only, not brief therapy. It's possible more frequent visits and brief therapy are enabling the patient to avoid starting their own weekly therapy which you likely cannot provide.

 

[FlowRate]

A subset of my "chronically depressed" patients are people who have some sort of negative life situation(s) and put zero effort into improving their situations. Some are "severely chronically depressed" but still working/functioning in life overall. It's hard to take those patients and think that going down the typical depression med algorithm is really going to fix anything. Usually med changes have little to no net effect when you do. I'm usually reluctant to recommend ECT for such presentations the way you might for people who literally can't get out of bed or take care of themselves.

 

[thelastpsych]

There's a lot going on here and I think the personality disorder piece is crucial here but I am struck by your description of having exhausted therapeutic options. Where are the TCAs, MAOIs, thyroid hormone, dopamine agonists, etc?

Haven't had much progress with thyroid hormoes thus far. TCAs are actually a good choice, and sometimes I see some patients improve with them, but usually I have to switch them off due to intolerability - patients keep complaining of excessive sedation even when taken at night or worsening of constipation (now that I've mentioned it, there seems to be a high prevalence of constipation in this population) to the point of asking to switch back to older meds. I don't actually have a lot of practice with dopamine agonists in this context - what are your recommendations on them? I've seen a few colleagues try, with mostly disappointing results.

 

[Celexa]

I have a few patients, usually females in their 40s or 50s, whom I inherited from past psychiatrists with a history of persistant and VERY impactful depressive symptoms (HAMD usually >30), with chronic suicidal ideation and almost no functionality in the real world.
The way I'm trying to approach these cases is:
1) Review the diagnosis, looking for secondary causes that may have been missed, and other psychiatric diagnosis such as personality disorders, OCD, PTSD, etc...no luck thus far, although a lot of these patients would definately fit in the "depressive personality" diagnosis some older psychatrists would use;
2) Try different and off-label approach: these patients have usually been tested on at least 2-3 SSRIs in max doses, with lithium/low dose-antipsychotics augmentation, with no benefitial result. I'm dealing with a population that does not have access to neuromodulation/ECT or even ketamine, so my therapeutic arsenal is already limited,
3) Try to engage these patients in behavioral activating activities, exercises, psychotherapy, group activities, OT, even meditation groups. Have had very little success as well - they don't want to go. They just come get their pills, usually haven't changed anything in their daily routines since the last appointment and complain about the same problems as always.

I try to have a more nuanced perspective nowadays, such as incentivizing and keeping record of small gains, and trying not to work more than the patient. But I keep feeling like I am missing something, I don't know. So, how do you usually approach these patients in the clinical interview to engage them more? What other resources could I use?

Thanks in advance!

Stop making med changes. If they want to keep seeing you and getting refills fine. But if the things that are going to actually change their life aren't in a pill bottle, stop feeding into the fantasy that pills have the answer by giving them another change.

 

[TheRightMedication]

I agree with the spirit of Celexa there, but I think it's appropriate to keep trying. We do, of course, need to be clear that med changes alone won't work, and to continually confront them with their non-adherence to the treatment plan (not exercising, not changing diet, not engaging in psychotherapy, sleep hygiene, et cetera.)

 

[clausewitz2]

Haven't had much progress with thyroid hormoes thus far. TCAs are actually a good choice, and sometimes I see some patients improve with them, but usually I have to switch them off due to intolerability - patients keep complaining of excessive sedation even when taken at night or worsening of constipation (now that I've mentioned it, there seems to be a high prevalence of constipation in this population) to the point of asking to switch back to older meds. I don't actually have a lot of practice with dopamine agonists in this context - what are your recommendations on them? I've seen a few colleagues try, with mostly disappointing results.

The classic idea of hypochondriacal depression (hypochondria = Latin 'abdomen' from Greek ὑποχόνδριος 'below the sternum') definitely emphasized chronic intestinal complaints as a core feature of the illness. Even Aubrey Lewis back in the day felt it was a characteristic feature of depression. Just sort of happenstance that it didn't make it into the DSM, really. There is a reason GI loves them some TCAs.

EDIT: I usually use pramipexole. There are papers out there that can provide detailed guidance but starting very low and increasing slowly is key to tolerability. People who have responded have mostly done so in the 2-3 mg range. It is by no means a miracle drug but sometimes very useful if someone seems to lack much in the way of hedonic drive.

 

[calvnandhobbs68]

Haven't had much progress with thyroid hormoes thus far. TCAs are actually a good choice, and sometimes I see some patients improve with them, but usually I have to switch them off due to intolerability - patients keep complaining of excessive sedation even when taken at night or worsening of constipation (now that I've mentioned it, there seems to be a high prevalence of constipation in this population) to the point of asking to switch back to older meds. I don't actually have a lot of practice with dopamine agonists in this context - what are your recommendations on them? I've seen a few colleagues try, with mostly disappointing results.

Why do they care if they're sedated if they have "almost no functionality in the real world"? They aren't distressed enough by their SI to tolerate some sedation (which often improves over time)? These are actually totally valid questions which makes me think they aren't actually that distressed by their "terrible depression". Sounds like they're feeling fine where they're at.

 

[clausewitz2]

Stop making med changes. If they want to keep seeing you and getting refills fine. But if the things that are going to actually change their life aren't in a pill bottle, stop feeding into the fantasy that pills have the answer by giving them another change.

Some variant of the conversation of "these pills work by making it easier for you to make changes in how you act and what you do in the world, without that none of them will ever work" is vital for your work with them to be useful.

 

[Candidate2017]

I have a few patients, usually females in their 40s or 50s, whom I inherited from past psychiatrists with a history of persistant and VERY impactful depressive symptoms (HAMD usually >30), with chronic suicidal ideation and almost no functionality in the real world.

Yes, there is a subset of persistently depressed middle aged females.

Yes, ECT, TCAs, etc. may help. But chronic is chronic. This is their baseline. They occasionally decomp, sometimes with serious suicide attempts, and go inpatient for a tune up. Then they sputter back to you. Like an old BMW.

Their relationships tend to be poor to non-existent in terms of spouse, children, and parents. The one person they have a functional relationship with is... you. It's remarkable that these patients who have no interest in doing anything can get themselves out of the house and come see you on a regular basis and take their meds. It's not the pills that keep them coming back. It's you. You do what you can. But chronic is chronic. Until death, whatever the cause may be. Accept this.

 

[thelastpsych]

There's a lot going on here and I think the personality disorder piece is crucial here but I am struck by your description of having exhausted therapeutic options. Where are the TCAs, MAOIs, thyroid hormone, dopamine agonists, etc?

EDIT: if you are able to provide therapeutic interventions yourself, you may want to take a look at CBASP, it was developed specifically for these people. It is not a small commitment, however.

Now that you've mentioned it clause, do you use any formal assessment method or scale/questionnaire to rule out personality disorders in this patient population?

 

[thelastpsych]

Why do they care if they're sedated if they have "almost no functionality in the real world"? They aren't distressed enough by their SI to tolerate some sedation (which often improves over time)? These are actually totally valid questions which makes me think they aren't actually that distressed by their "terrible depression". Sounds like they're feeling fine where they're at.

Good point actually. As someone with not that much experience outside of residency, I usually take some complaints at face value, when I should be a bit more skeptical, and dig around a bit more. Will keep that in mind.

 

[calvnandhobbs68]

Now that you've mentioned it clause, do you use any formal assessment method or scale/questionnaire to rule out personality disorders in this patient population?

I mean anyone who's presenting for "years" of constant reported "depression" you should probably have a high suspicion of interfering personality traits. I'd personally take the opposite approach and be trying to rule-in a personality disorder. Some people are just kind of dysthymic too (although one could argue that dysthymia should really be a type of personality disorder)....I've definitely had those "Eeyore" dysthymic patients who just insist that nothing really helps for years.

 

[Celexa]

I agree with the spirit of Celexa there, but I think it's appropriate to keep trying. We do, of course, need to be clear that med changes alone won't work, and to continually confront them with their non-adherence to the treatment plan (not exercising, not changing diet, not engaging in psychotherapy, sleep hygiene, et cetera.)

I turn to what I consider my 'stubborn broken record mode' when either the patient has truly been through multiple steps of a rational evidenced-based medication approach with true trials, OR has stopped said steps before getting to true trials due to side effects/unclear reasons etc and I've hit a brick wall on the latter despite my best encouragement and psycho education. In both cases the utility of continuing med adjustments is VERY low, as you are likely interacting with a personality component which is leading to a strong nocebo effect (or, someone for whom meds just aren't going to work for unknown physiologic reasons we aren't in a position right now to identify).

The act of refusing to make medication changes is not necessarily permanent, and does not involve terminating care. It is diagnostic and frequently therapeutic. How does a patient react when you do it? A significant chunk of these flailing cluster Cs (and they are usually C, not B) initially get angry that you call their bluff, but once you've made it clear you aren't going to continue providing a maladaptive justification for why they don't get better, they'll actually start making changes. And if they don't, you're no worse off then before. There's nothing to fear in their reaction, only useful information. I start making medication changes again when they can show me they believe it might work. Agreement with your recs about med changes doesn't mean the pt actually believes the meds will help, thus the nocebo.

 

[pyrrion89]

Agree with all the points here.

On the topic of the patient who is hopelessly chronically depressed, "tried everything", but unwilling to try anything different, provided they are not severely depressed/suicidal:

If they are help-seeking/help-rejecting chronically depressed patients, then show them STAR-D showing the odds of medication #6 working are less than 10% (probably closer to 1-5%) and that they need to find a therapist, and that seeing you for fake therapy (venting/complaining for 20 minutes every 1-2 months) will provide a very temporary relief that won't actually make them improve. Of course you have to try to do that sympathetically, which can be challenging (at least for me).

Give them options (they need to learn to be self-efficacious) and they need to pick one.
1. Go do TMS, ECT, ketamine, IOP if they are really sick but not suicidal.
2. Do not recommend another medication if they haven't really done therapy. So tell them to go get a therapist who actually does CBT/ACT, etc, not rent-a-friend
3. Behavioral activation
4. Continue medication and meet less often (explain you can do "med management" but they need more, but that their medications are not complex enough to really be seen all the time).

If they fail to agree to make a choice, then you can let them know they are wasting their time (i.e., also your time) and they can come back when they feel ready to make a choice, and do not offer them a follow-up. Tell them to schedule later, should they choose to.

 

[annoyedpsychiatrist]

everyone is basically already saying this, but we need to always remember that pills arent necessarily the magic answer for depression. A pill is a supplement to lifestyle and behavioral changes, and not vice versa. My intent with prescribing pills to treat moderate-severe depressive episodes that are pathological, not chronic depression stemming from life choices, thinking patterns, poor lifestyle habbits, etc. Pills do not work for this. My aim in psychiatry is always to deprescribe whenever I can, not continuously add to the medication list.

One thing I ask depressed patients, "When was the last time you were happy?". If they say "never". How would you even know what happiness is then? What does it mean to be happy? What do they expect that happiness feeling to feel like?

When patients come in and endorse severe persistent depression for 30 years and have been on 50 antidepressants, usually the issue isnt the medication.

 

[Celexa]

One thing I ask depressed patients, "When was the last time you were happy?". If they say "never". How would you even know what happiness is then? What does it mean to be happy? What do they expect that happiness feeling to feel like?

My version of this is "when was the last time you felt well?" and it is one of my favorite intake questions. I ask basically everyone. The answers are incredibly revealing.

 

[comp1]

I adore the "when did you last" questions of all types when they focus on the positive, particularly asking chronically suicidal patients what was going on in their life when they last weren't suicidal. Patients come so intently focused on what is wrong. It's seriously our job to reframe that into the resources and coping skills they do have. Never or always are very important answers, even if they can feel hyperbolic. I'm not going to say it's absolutely pathognomonic for personality pathology, but personality disorders, unlike mood disorders, are not clearly episodic and feeling depressed or suicidal or any particular way for the entirety of one's remembered life could indeed be very consistent with primary personality pathology.

 

[Celexa]

I adore the "when did you last" questions of all types when they focus on the positive, particularly asking chronically suicidal patients what was going on in their life when they last weren't suicidal. Patients come so intently focused on what is wrong. It's seriously our job to reframe that into the resources and coping skills they do have. Never or always are very important answers, even if they can feel hyperbolic. I'm not going to say it's absolutely pathognomonic for personality pathology, but personality disorders, unlike mood disorders, are not clearly episodic and feeling depressed or suicidal or any particular way for the entirety of one's remembered life could indeed be very consistent with primary personality pathology.

So I've got no hard data but I tend to find the nevers to be more likely trauma-based (doesn't exclude personality pathology but doesn't require it either) with "happy/well" meaning 'safe' which they never have felt. And their histories are consistent with a life lived on the edge. The more firmly personality folks tend to have the dysthymia more in the entire or majority of their adult life (or consistently since an inflection point years prior) but not necessarily 'never'. Or they SAY never, but when you probe their life timeline you actually find periods of contentedness they have a hard time acknowledging.

The trauma folks frquently do need meds to reign in their hypervigilence etc symptoms enough for therapy and often pretty willing to engage if it's available. The cluster c chronic depressive personality the meds often seem meaningless when you back up and look at the big picture and resist any therapy that requires effort.

 

[Stagg737]

Never or always are very important answers, even if they can feel hyperbolic. I'm not going to say it's absolutely pathognomonic for personality pathology, but personality disorders, unlike mood disorders, are not clearly episodic and feeling depressed or suicidal or any particular way for the entirety of one's remembered life could indeed be very consistent with primary personality pathology.

I also like the "when did you last" questions, especially for patients reporting chronic problems or inefficacy of meds. It doesn't need to represent a personality "disorder" or even necessarily pathology depending on how you define pathology. I do agree that for these patients that this is more of a "psychological" vs "biological" etiology though, and that medications are rarely efficacious without significant therapy or psychosocial interventions. I've found that really diving into cognitive distortions, setting realistic goals, and reframing with concepts of ACT in mind to be quite beneficial for many of these people when they've got fair insight.

3) Try to engage these patients in behavioral activating activities, exercises, psychotherapy, group activities, OT, even meditation groups. Have had very little success as well - they don't want to go. They just come get their pills, usually haven't changed anything in their daily routines since the last appointment and complain about the same problems as always.

I try to have a more nuanced perspective nowadays, such as incentivizing and keeping record of small gains, and trying not to work more than the patient. But I keep feeling like I am missing something, I don't know. So, how do you usually approach these patients in the clinical interview to engage them more? What other resources could I use?

Sometimes I will bluntly ask the patients why they keep coming to see me if nothing we try is helpful and also will occasionally point blank ask them if they actually want to get better. The response is often "of course I do!", but when I point out all the things they're unwilling to try or have "tried" we can really start diving into their motivations. Once you figure out what they're actually getting out of the appointments, then you can start figuring out if what you're doing is actually therapeutic or how to move forward. I agree with Celexa that many of these patients have some level of cluster C trait pathology that's meds just aren't going to touch.

 

[Crayola227]

Why do they care if they're sedated if they have "almost no functionality in the real world"? They aren't distressed enough by their SI to tolerate some sedation (which often improves over time)? These are actually totally valid questions which makes me think they aren't actually that distressed by their "terrible depression". Sounds like they're feeling fine where they're at.

Eh, sedation feels different than depression and I'm not terribly surprised that you still get complaints about sedation despite very significant depression. And depending on how much the depression is actually alleviated, the combo might be downright intolerable. The thing about being held back by depression, is that the nature of depression makes it hard to really even care about the deficit. Sure you can still have significant distress about it all, but people can feel various levels of indifferent to it or detached or like it's all upsetting in a more abstract fashion.

What can feel worse for some patients is getting back their oomph and their pleasure and drive and feeling of being present, feeling things in a more immediate way, and then feeling held back by sedation. Sometimes if the patient pushes past this, the depression improves to a point and the sedation decreases to a point that the mix is better than before. But not always.

In my experience a lot of people experience sedation as being unable to think, not just the physical heaviness it can bring which is also similar to depression. Depression can impact this subjectively as well of course. But many depressed people still have coping mechanisms like watching TV or video games or what have you, so feeling like they can't do that owing to mental slowing or sleepiness from sedation could itself feel very distressing.

Plus there is a difference between tired and sleepy, and depression tends to be more the former rather than the latter. Even severely depressed and subjectively "tired" individuals can still drive, however sedation can make that a very dangerous proposition indeed even for the otherwise healthiest person.

What is worse, not caring to eat the sandwich you could make in the kitchen, or wanting to get up and eat it but feeling too sedated to feel like you can get it together to do so? Not wanting to drive somewhere, or wanting to but you can't? This is all very subjective and the values of the patient and the trade offs I feel are relevant.

Anyway, I would not handwave sedation as a medication side effect away, even if the medication did improve other symptoms of depression. If it did not do enough to relieve severe depression to a substantial degree, adding in any sedation as a symptom on top of everything else could be just awful.

In any case, the way that I've seen resistance to treatment in the setting of profound depression and SI, is a provider saying something along the lines of, based on what you are telling me, you have tried so many things, but you are in the fight of your life. You are fighting for your life. So it's time to do something. Insert tolerating whatever side effect/doing whatever thing they are not doing. At least it's worth a try.

I have seen this approach work several times. I'll spare why I think it works sometimes. Obviously plenty of patients that this will do nothing. But when nothing else works, it's worth a try to be that blunt and frame it in those terms, because surprisingly it does take sometimes.

 

[Crayola227]

Yes, there is a subset of persistently depressed middle aged females.

Yes, ECT, TCAs, etc. may help. But chronic is chronic. This is their baseline. They occasionally decomp, sometimes with serious suicide attempts, and go inpatient for a tune up. Then they sputter back to you. Like an old BMW.

Their relationships tend to be poor to non-existent in terms of spouse, children, and parents. The one person they have a functional relationship with is... you. It's remarkable that these patients who have no interest in doing anything can get themselves out of the house and come see you on a regular basis and take their meds. It's not the pills that keep them coming back. It's you. You do what you can. But chronic is chronic. Until death, whatever the cause may be. Accept this.

Very well said. I will point out a few things. I have seen males that fit the above to a complete T. However the isolated older male, do we think it's possible that for various reasons they simply don't present to a provider and keep doing so as consistently as females might? I think there may be a bit more of a cultural effect here.

If we were to make a generalization about females being more prone to depression vs more prone to identify it and seek treatment, all of which may be true, beyond cultural effects I think it's reasonable to consider hormonal reasons.

Thyroid hormone was mentioned.

However, and it absolutely deserves mentioning, is perimenopause or postmenopausal symptoms. Recently I've been made more aware the degree to which this can cause the sort of mental health issues described in this thread.

As far as testing, my understanding is that hormone testing regarding peri/post menopause has a lot more to do with diagnosing onset/completion of the change but is generally not needed for confirmation unless as part of a fertility work up. And that hormone levels in this setting do not relate to severity of peri/post menopause symptoms, nor does it guide hormone therapy for relief.

Now, as far as hormone therapy for mental health related symptoms, that I am quite ignorant on.

If anyone has any thoughts vis a vis menopause, mental health, and treatment, I would be very interested to learn more.

I'm a little surprised/not surprised no one has mentioned menopause despite the comments about post menopausal women and their mental health issues.

 

[Crayola227]

Why do they care if they're sedated if they have "almost no functionality in the real world"? They aren't distressed enough by their SI to tolerate some sedation (which often improves over time)? These are actually totally valid questions which makes me think they aren't actually that distressed by their "terrible depression". Sounds like they're feeling fine where they're at.

So people are now saying, well, PD.

What evidence do we have the patients are "feeling fine"? Don't PDs also cause distress, by definition? So regardless of dx, couldn't these patients not be "feeling fine"?

What evidence do we have they are "feeling fine" despite their subjective report? I don't imagine this is quite like the patient in the ED with 10/10 pain calmly eating a ham sandwich. I mean I suppose you could have someone with a report like this that then in the session has a normal or happy affect describing all kinds of feelings and activities that sounds like feeling fine and functioning.

But outside of that, I fail to see how having a distressing symptom like sedation in lieu of depression is evidence of feeling fine?

In any case, while I would agree you have your "eeyore" types, chronic mild depressives vs dysthymic vs whatever you want to describe this population as, and while they may not do much about it, make changes, get better, and just truck along, low risk of suicide, I don't know that means they are "feeling fine." Unless you mean "doing fine," which I agree isn't the same thing. Some of these people "do" OK however you want to define that. But not the same as feeling fine.

It's well and good if you want to declare they will do "OK" and there isn't much to do for them, but I would hesitate to label them and their distress this way. Maybe it's a provider's coping mechanism. Otherwise I fail to see what it adds to the relationship or treatment, and I could see the attitude doing a disservice.

 

[Crayola227]

everyone is basically already saying this, but we need to always remember that pills arent necessarily the magic answer for depression. A pill is a supplement to lifestyle and behavioral changes, and not vice versa. My intent with prescribing pills to treat moderate-severe depressive episodes that are pathological, not chronic depression stemming from life choices, thinking patterns, poor lifestyle habbits, etc. Pills do not work for this. My aim in psychiatry is always to deprescribe whenever I can, not continuously add to the medication list.

One thing I ask depressed patients, "When was the last time you were happy?". If they say "never". How would you even know what happiness is then? What does it mean to be happy? What do they expect that happiness feeling to feel like?

When patients come in and endorse severe persistent depression for 30 years and have been on 50 antidepressants, usually the issue isnt the medication.

Completely agree here.

It is a fine point to make though, that the answer about never feeling happy/functional can be misleading. Depression affects the lens that patients use to interpret reality or the past. It can actually just be a further symptom of depression to think that one has NEVER been happy/functional, "not really" for whatever reason. Discounting the positive, essentially. Buying into this negative belief that they have never been happy and never will be happy. Sometimes it takes improvement for patients to realize that depression was not the totality of their existence, and hey, now I remember what feeling good feels like and I have felt good before, how bizarre when being depressed that I couldn't remember having felt not-depressed before.

Now, your last example does definitely suggest what I'm saying here isn't the issue. But I think it deserves pointing out that sometimes you have to be skeptical about the answer to your question, if it is a symptom of something with remedy or not.

But as I said, this is a side note and not really a rebuttal to what you're saying.

 

[Crayola227]

So I've got no hard data but I tend to find the nevers to be more likely trauma-based (doesn't exclude personality pathology but doesn't require it either) with "happy/well" meaning 'safe' which they never have felt. And their histories are consistent with a life lived on the edge. The more firmly personality folks tend to have the dysthymia more in the entire or majority of their adult life (or consistently since an inflection point years prior) but not necessarily 'never'. Or they SAY never, but when you probe their life timeline you actually find periods of contentedness they have a hard time acknowledging.

The trauma folks frquently do need meds to reign in their hypervigilence etc symptoms enough for therapy and often pretty willing to engage if it's available. The cluster c chronic depressive personality the meds often seem meaningless when you back up and look at the big picture and resist any therapy that requires effort.

I should have read this first before replying 🤣

 

[annoyedpsychiatrist]

Completely agree here.

It is a fine point to make though, that the answer about never feeling happy/functional can be misleading. Depression affects the lens that patients use to interpret reality or the past. It can actually just be a further symptom of depression to think that one has NEVER been happy/functional, "not really" for whatever reason. Discounting the positive, essentially. Buying into this negative belief that they have never been happy and never will be happy. Sometimes it takes improvement for patients to realize that depression was not the totality of their existence, and hey, now I remember what feeling good feels like and I have felt good before, how bizarre when being depressed that I couldn't remember having felt not-depressed before.

Now, your last example does definitely suggest what I'm saying here isn't the issue. But I think it deserves pointing out that sometimes you have to be skeptical about the answer to your question, if it is a symptom of something with remedy or not.

But as I said, this is a side note and not really a rebuttal to what you're saying.

your point is very valid in that people who are significantly depressed see things as glass is half empty. for sure agree with you. I mainly ask the question to open the door for discussion and often I use it to make several points, actually ill even use to link towards CBT and your point. If you perceive everything in a negative light, than isnt it logical you would feel depressed at all times? I like the question but i can use it to hammer quite a few points to the patient. My goal is to create an answer and make them start thinking. Depression leads to complacent behavior, and I want them to question their beliefs. Im a very hardcore believe in CBT, and try to really talk to my patients.

 

[dozitgetchahi]

A subset of my "chronically depressed" patients are people who have some sort of negative life situation(s) and put zero effort into improving their situations. Some are "severely chronically depressed" but still working/functioning in life overall. It's hard to take those patients and think that going down the typical depression med algorithm is really going to fix anything. Usually med changes have little to no net effect when you do. I'm usually reluctant to recommend ECT for such presentations the way you might for people who literally can't get out of bed or take care of themselves.

Rheumatology here. As you might imagine, a lot of these types of depressed, achy, anhedonic patients eventually darken my door under the label “fibromyalgia”, “CFS” etc. So I’ve had some experience in dealing with them, and trying to move them towards some sort of a better life.

You all have mentioned a lot of what we in the rheumatology community have observed both in clinical practice and in research - medication by and large doesn’t work but changing lifestyle potentially does. A lot of what I do with these patients is very “holistic” and really resembles “life coaching” more than medicine. I explain to people that there are things in life that can help you feel good or bad depending on how they’re managed - sleep, exercise, stress, inflammation, pain etc. So getting bad fibro better is very much about getting as many of these things to point “up” instead of pointing “down”.

The rheum literature indicates that two things help these folks: 1) aerobic exercise and 2) sleep hygiene. So obviously I push these hard. “Graded aerobic exercise protocol” is my favorite phrase for these folks. You may have to start very very low if they’re deconditioned. I sometimes recommend just 5 minutes of walking a day to start, or even 1 minute, or hell even just walk to your front door and back. Then, gradually ramp it up. A lot of these folks have undiagnosed sleep apnea, so I do a fair number of sleep studies. I’ve also seen that some of these folks have had undiagnosed autoimmune conditions like RA - and sometimes getting them properly treated for that has had dramatic effects. The brain doesn’t work well when it’s constantly hammered with cytokines.

I fully agree that “life stressors” play a role. A lot of these patients are in abusive relationships, family is taking advantage of them, they’re at a job where they’re treated horribly, etc. “Life changes” is the name of the game.

Also, a number of these patients come in on huge medication lists and I have had some success in just stopping meds - some of the malaise and lousy feelings etc that patients register as “depression” have been from medication side effects in past patients. Don’t be afraid to deprescribe.

These are exhausting, wide ranging appointments and I don’t always enjoy them. When you can achieve a breakthrough and someone starts moving and feeling better, it’s obviously great, but that happens less frequently than one would hope.