Uncharted Territory: The treatment-resistant depressed patient who is chronically suicidal

[whopper]

Case example: Patient is severely depressed as measured by a depression scale, but is able to stay independent. All SSRIs, SNRIs, Wellbutrin, Mirtazapine, Parnate, and 3 TCAs have also been tried at therapeutic dosages for over 1 month each. Also combinations have been tried, as well as augmentation medications (Buspirone, low dosage antipsychotic, low dosage antipsychotics indicated for depression, Lamotrigine), TMS, Esketamine, and still the patient is still depressed with no significant benefit.

What to do? The patient is suicidal so you send him to inpatient and he's discharged 3 days later with no benefit. Plus you see no reason to think that trying another med that was already tried would work. All the labs that would suggest a physical cause are negative such as his TSH, B12, and folic acid being within a normal range.

Psychotherapy was already tried with a few therapists and with myself. Still no improvement. Also he has no signs of a personality disorder. He's hard working, polite, his friends and family say he is a very nice person.

His mother has chronic depression but we tried all the meds that worked on her and no improvement.

Pharmacogenetic testing offered no improvement. All of it's recommendations were tried.

ECT, Deep brain stimulation, and VNS were offered as options. He doesn't want any of them. He's to the point where he doesn't want to try any other regimen that already has been tried before or any combinations of meds that are made of meds he's already tried before which is pretty much all of the ones indicated for depression.


So what do you do?
Still carry this guy? If he commits suicide you could be a high liability cause he's suicidal and you knew he was for months. If you send him to the hospital you know they'll simply just discharge him a few days later with no improvement. Cowardly teriminate him because you don't want a hard patient?

I have no answer but will say if you terminate this guy you're taking the easy way out and possibly thinking more about yourself than your patient's well-being.

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[FatherPsychiatry]

Not trying to be facetious, but as one of my old, hard but wise attendings would always ask - why hasn't he killed himself yet? Any prior suicide attempts? What does his "suicidality" entail? When was the last time he wasn't depressed?

 

[whopper]

why hasn't he killed himself yet? Any prior suicide attempts? What does his "suicidality" entail? When was the last time he wasn't depressed?

No prior attempts. I did a Columbia Suicide Scale.

The glaring thing in the record was he researched ways to die. He looked up fatal dosages of varying meds. I was ready to pull the trigger and send him to the hospital at that moment but a friend intervened and agreed to stay with him for several days. It's been months since then.

He is future-oriented. He loves his family and knows committing suicide would devastate them. He hates his job but continues to work at his because he doesn't want to go into financial ruin. He just got a lower interest rate on his home mortgage.

There is the cluster B patient who is frequently parasuicidal, perhaps even suicidal and residents often times get good experience in dealing with that type of "suicidal."

This is a very uncomfortable zone. Hospitalization won't work (he'll refuse ECT and they can't offer him a new med he hasn't tried before), and if anything will only make the guy feel worse, he's treading on commitment criteria, and yet despite all this I have no treatments I believe can work other than perhaps ECT that he doesn't want to try.

I do have a few other chronically suicidal-treatment resistant patients that will not commit suicide only evidenced by them being this way for years. They often times have something that prevents them from doing it. Also such patients will not benefit from hospitalization because there really is no med the hospital can offer that'll help and the patient either already did ECT and it didn't help or they don't want it. While this patient has factors they're not strong enough to the point where I feel comfortable. Yet not enough in the other direction to make me make him to go the hospital and even if so, like I said they'll just discharge him a few days later.

 

[robellis]

You just keep trying, there’s not really much you can do. We have to accept that there are some people who are so biologically messed up that they will simply never improve. Does that mean you stop trying or terminate? No, of course not, you keep trying but that perspective will give you hope to move forward without burning yourself out. Just like how there are treatment resistant infections, cancers, etc there are these patients.

 

[whopper]

The easy way out is for me to terminate him. I won't have to deal with the legal repercussions of keeping a difficult patient. That will entail him getting a new psychiatrist who will have to start all over. Further, and let's be frank, lots of psychiatrists only spend a few minutes with patients. I am confident he will likely not get care as good as I can provide.

As of this time I will not terminate him because I believe doing so is pretty much the coward's way out and I'd only be doing it to save my own butt and not out or regard for him.

I did refer him to treatment resistant clinics. One of the best in the nation is in my area. I also referred him to institutions that specialize with highly regarded treatment and quality such as the Lindner Center and the Meninger Clinic. Also he's been seen by 2 other doctors in the area who are considered top in the field who also couldn't get him better.

IOP in my area I have no confidence cause I've already seen too many try this and they told me the psychiatrist saw them for 5 minutes and they were simply in group therapy all day that wasn't specific to their problem.

This is really a zone where I don't like it. I actually don't mind having a patient that's doing bad and needs a lot of intense effort. I mind the possibility that if the guy kills himself a legal armageddon can happen despite that I am doing above the standard of care and could take years to resolve.

 

[clausewitz2]

So many questions. The ones that come straight to mind, in no particular order:

1) does he actually want to die, or does he just think about suicide and tell people he is thinking about suicide a lot?
2) how exactly is he scoring so highly on depression scales and maintaining a reasonable semblance of work and family life? Consider individual response characteristics.
3) if suicidality is a genuine concern, why on earth has he not been tried on lithium? Upside is it might also help, or at least has a decent chance. Regardless, harder to argue you were negligent if he does attempt/complete if you are prescribing him one of two meds known to reduce risk of drying by suicide
4) how do you define adequate dose of Parnate?
5) consider teaching DBT skills, may be helpful for tolerating suicidal impulses for possibly the rest of his life.

 

[clausewitz2]

Also talk to him with his family and make it clear you will keep working with him but that they need to understand he is at a high risk for suicide (if you indeed think he is) and you cannot guarantee it will not happen. Set expectations appropriately and you're way less likely to get sued.

 

[hebel]

Very tough situation. Things that come to mind: lithium, exercise, trauma history?, MAPS, how good was the therapy?, would others say he seems depressed or just his self report? Any benefit(s) from being in a sick role?

Therapy quality can vary vastly, and there's some people out there who can get pretty impressive results with therapy even with these tough cases. I've been impressed by some of the ISTDP therapists results.

 

[kopftonmd]

This feels very much like the patient needs ECT. When he's been sent inpatient, has that been voluntary or involuntary? It doesn't feel kosher but in theory it seems like it's possible to administer ECT to an involuntary patient (source, #10, and some more data).

That said, if he does have capacity and he doesn't want ECT/TMS/Ketamine/any other reasonable option, I still think he's worth keeping as a patient. You clearly have some amount of rapport with him and even if you're not getting a lot of treatment traction, having a stable relationship with a psychiatrist seems that it would be good just to have. What I think this patient requires though is documentation at every visit, expressing:
- The objective data you've been gathering and tracking
- All of the things you've tried
- The referrals you have offered
- His refusal to try other treatment modalities, and your having counseled him on them
- That he has capacity to refuse and why
With all of that documented, I can't see why a reasonable person would hold you liable if there were to be a suit. I'm thinking of it as like a patient who has known cancer but won't get it treated: we all know that they're at risk of death, but the physician shouldn't be held responsible for their autonomous decision not to pursue treatment, provided that all of the counseling has been done.

 

[AD04]

You mentioned a high legal risk. But how high is it if your care meets standard of care? And it seems like it does.

Where I'm at, there is no one else to punt off difficult patients to. I am the last resort. I am doing ECTs for half the state. I am taking on the difficult cases. And based on statistics, some will kill themselves due to the elevated chronic risk. If physicians are punished for taking on difficult cases, then no one will take on these cases.

 

[Crayola227]

Some people just seem to get stuck in these thought loops, frankly I wonder if there's some OCD component to it, or something else. Or it's just a thought pattern, I think that can happen in otherwise normal individuals.

I agree about trying lithium. Perhaps his chronic depression/suicidality yet preserved function is some sort of mild variant in the bipolar realm. ..? That may make zero sense but...

(I think we've talked in this forum about to what extent does unipolar depression vs bipolar disorder present separate illnesses with a unique basis in the brain and hence different responses to meds vs a continuum vs bipolar is like unipolar depression plus special features.... I have no idea)

in any case if his depression/suicidality isn't responding to typical treatment maybe it's time to treat it like something else.

What do you do for OCD/anxiety that aren't the meds you have used so far? I shudder to suggest benzos of course....

As far as ECT, and I don't know the best way to put this to this guy, but at some point when you're treating a disease, you have no choice. That's what it means to be sick. Like with cancer, you get left with limited choices, and none of them are good or anything you really want. If you're really fighting for your life you do whatever you have to do. I've seen some psych have this kind of tough love talk and it worked. Lithium and ECT can have some real side effects, but a lot of ppl that have held out for years and finally do it, can't believe they didn't do it sooner, even if they do suffer side effects. He also has his family to consider.

If he's otherwise compliant I don't see a reason to terminate. I understand the liability but all docs have liability and I think what people said here about CYA makes a lot of sense. I've never been sued so it's easier for me to say I'd feel better about that then terminating this guy and then later he offs himself than if he were to stay my patient and then I get blamed.

 

[the5thelement]

It seems more likely external factors not amenable to biological therapy :"He hates his job but continues to work at his because he doesn't want to go into financial ruin"
Life ultimately means taking the responsibility to find the right answer to its problems and to fulfill the tasks which it constantly sets for each individual.
Has he read "mans search for meaning " by Viktor Frankl?

 

[clausewitz2]

If we're just talking about other medications that might help and have at least some evidence and I think with the right risk benefit discussion you could justify, here's a non-exhaustive list:

Lithium
Tegretol
Supra-physiologic thyroid hormone (T4 or T3)
Pramipexole
Methylphenidate
Amphetamines
Minocycline
Nimodopine
Reserpine
Very low dose suboxone
Dextrometorphan + wellbutrin/quinidine
Marplan
Phenelzine
Nortriptyline + sertraline
Nortriptyline + lithium
Nortriptyline + MAOI
MAOI + Ritalin
Ketamine

 

[clausewitz2]

Some people just seem to get stuck in these thought loops, frankly I wonder if there's some OCD component to it, or something else. Or it's just a thought pattern, I think that can happen in otherwise normal individuals.

I agree about trying lithium. Perhaps his chronic depression/suicidality yet preserved function is some sort of mild variant in the bipolar realm. ..? That may make zero sense but...

(I think we've talked in this forum about to what extent does unipolar depression vs bipolar disorder present separate illnesses with a unique basis in the brain and hence different responses to meds vs a continuum vs bipolar is like unipolar depression plus special features.... I have no idea)

in any case if his depression/suicidality isn't responding to typical treatment maybe it's time to treat it like something else.

What do you do for OCD/anxiety that aren't the meds you have used so far? I shudder to suggest benzos of course....

As far as ECT, and I don't know the best way to put this to this guy, but at some point when you're treating a disease, you have no choice. That's what it means to be sick. Like with cancer, you get left with limited choices, and none of them are good or anything you really want. If you're really fighting for your life you do whatever you have to do. I've seen some psych have this kind of tough love talk and it worked. Lithium and ECT can have some real side effects, but a lot of ppl that have held out for years and finally do it, can't believe they didn't do it sooner, even if they do suffer side effects. He also has his family to consider.

If he's otherwise compliant I don't see a reason to terminate. I understand the liability but all docs have liability and I think what people said here about CYA makes a lot of sense. I've never been sued so it's easier for me to say I'd feel better about that then terminating this guy and then later he offs himself than if he were to stay my patient and then I get blamed.

I had the OCD thought as well, suicide OCD can be easy to miss (or interpret as genuine suicidality). If that captures it better think about memantine, NAC, clomipramine/SSRIs in great whopping doses.

 

[Mindfulpsych22]

I'm curious about the comment that "psychotherapy was tried with various therapists." What does this mean exactly? Did he "try" various therapies or did he do similar therapy with different therapists? Did he do any of the gold-standard, empirically supported treatments for chronic depression (or OCD if that is believed to be a contributing diagnosis) with therapists who are trained to an expert level in these therapies and deliver them adherently? What does "try" mean exactly? Did he actually fully participate and complete a full course of therapy (do all interventions and recommendations for the length of time recommended by the therapist) or stop part-way through thus making it hard to know if the therapy failed or if the therapy was incomplete?

 

[clausewitz2]

Maybe the most important question of all to ask: When were things last okay? When did he last feel alright about his life?

'Five years ago' leads in very different directions than 'Never'

 

[Alemo]

Wow, that right there is what, two years minimum of a different antidepressant every month? Do these patients exist?
I mean, I understand the point of the exercise.....

All SSRIs, SNRIs, Wellbutrin, Mirtazapine, Parnate, and 3 TCAs have also been tried at therapeutic dosages for over 1 month each. Also combinations have been tried, as well as augmentation medications (Buspirone, low dosage antipsychotic, low dosage antipsychotics indicated for depression, Lamotrigine), TMS, Esketamine, and still the patient is still depressed with no significant benefit.

 

[clausewitz2]

Wow, that right there is what, two years minimum of a different antidepressant every month? Do these patients exist?
I mean, I understand the point of the exercise.....

I read a study the other day looking at a group of treatment resistant depressed patients. Median number of failed medication trials was 17. Unfortunately in the literature treatment resistance can mean anything from 2 failed trials to, well, that

 

[Psychresy]

Have an attending who swears by dopamine agonists if there is an elevated CRP

 

[whopper]

There is data showing with higher CRP and treatment resistance dopamine based meds could work better. I don't have the data on me for easy reference at the moment.

1) does he actually want to die, or does he just think about suicide and tell people he is thinking about suicide a lot?
2) how exactly is he scoring so highly on depression scales and maintaining a reasonable semblance of work and family life? Consider individual response characteristics.
3) if suicidality is a genuine concern, why on earth has he not been tried on lithium? Upside is it might also help, or at least has a decent chance. Regardless, harder to argue you were negligent if he does attempt/complete if you are prescribing him one of two meds known to reduce risk of drying by suicide
4) how do you define adequate dose of Parnate?
5) consider teaching DBT skills, may be helpful for tolerating suicidal impulses for possibly the rest of his life.

1) He states he doesn't want to die but as we all know a contract for safety is meaningless in a legal sense. He is not cluster B and not attention seeking so when a girlfriend told me he was researching ways to die I was about to pull the 9-1-1 trigger but the friend intervened as mentioned above.
2-Depression scales are SEVERE. Maintaining work. Lives alone that is making this also very difficult because there's no immediate people that can see him and report to me how he's doing. Next of kin are in another state. Girlfriend is in another state. When I say other state I don't mean across the river. I mean on the other side of the country.
3-Lithium was tried. No benefit.
4-Parnate already tried, high dosages, No benefit.
5-DBT skills? Already went through several therapists and he has no cluster B traits. While DBT might help and wasn't tried yet I've questioned if this should be tried given that this is not a cluster B problem.

Also answering some questions above, how much of this is his job? He does mention the job is toxic and hates it but had depression long before this job, and also has a strong family history of depression leading me to believe this is highly physiological and external situation. I already recommended he consider getting a new job but his depression is to the degree where he tells me he doesn't have the energy to find one but will stay with his current job.

Some things I haven't tried are very out of the box. E.g. Buprenorphine, Pramipexole, Amantadine.

ECT? Doesn't want it and it's next to impossible to get involuntary ECT done even when the patient is hospitalized against their will.

 

[Stagg737]

What to do? The patient is suicidal so you send him to inpatient and he's discharged 3 days later with no benefit. Plus you see no reason to think that trying another med that was already tried would work. All the labs that would suggest a physical cause are negative such as his TSH, B12, and folic acid being within a normal range.

Testosterone? I've been on 2 cases where basically catatonic patients who didn't respond to Ativan improved rapidly with starting Testosterone after their only abnormal test was Low-T.

Also he has no signs of a personality disorder. He's hard working, polite, his friends and family say he is a very nice person.

Are you really, really, really sure? I have one or two patients who I think meet the criteria for depressive PD better than any actual current DSM diagnosis and as expected, medications seem to be largely inefficacious. High functioning PD patients can also do very well at points until put in the right situation when things crumble. I have a BPD patient who did well for about 1.5 years after moving to a more accepting geography and completely fell apart after a specific event. He's doing much better, but during that 1.5 years showed almost no signs of a PD per previous records. How long have you had this patient? Are you sure they're always as high functioning as is reported?

ECT, Deep brain stimulation, and VNS were offered as options. He doesn't want any of them. He's to the point where he doesn't want to try any other regimen that already has been tried before or any combinations of meds that are made of meds he's already tried before which is pretty much all of the ones indicated for depression.

Also, any other psychotropics been tried? LSD? Ayahuasca? I have a co-resident who will likely have an interesting case report involving complete remission of depression and chronic SI after a suicide attempt with LSD. Total remission has apparently continued for 6 months post SA without further dosing or medications. We've also had a few patients who regularly go to "religious" meetings to use Ayahuasca every few months for their depression who do pretty well.

1) does he actually want to die, or does he just think about suicide and tell people he is thinking about suicide a lot?
2) how exactly is he scoring so highly on depression scales and maintaining a reasonable semblance of work and family life? Consider individual response characteristics.

I had some similar questions. "What keeps you alive?" "Why haven't you attempted?" or even "So why are you still alive?" are all questions I've asked in the right context. I've even asked a couple patients "Do you actually want to get better?" in the right context (mostly likely would avoid that one with OP's patient). How much intent is behind these thoughts. Are the thoughts always there are are there specific triggers?

How has the depression actually been measured? I'm assuming much more than just Columbia, but has he had actual psych testing? Has everything else been fully ruled out? OCD? OCPD? TBI? Inattentive ADHD? Any other disorders where patients can become hyperfocused on a topic?

Wow, that right there is what, two years minimum of a different antidepressant every month? Do these patients exist?
I mean, I understand the point of the exercise.....

I currently have a borderline patient who has been on at least 25 different meds but absolutely refuses to do therapy.

 

[whopper]

Testosterone within normal range.

I've never detected any personality disorder, talked to his prior psychiatrist who agreed, but I referred him for personality testing just to see if there's anything I'm missing. Waiting for results.

LSD? I actually would like this to be tried but have no way to access it. I actually do think micro-dosing would be appropriate given his treatment resistance.

No TBI. No ADHD. No OCD. No formal testing but he is a very coherent interviewer. The guy's academic history is extremely impressive and he researches everything I tell him to do. If those were missed I figure an MMPI that I referred him to do will hopefully catch.

 

[clausewitz2]

1) He states he doesn't want to die but as we all know a contract for safety is meaningless in a legal sense. He is not cluster B and not attention seeking so when a girlfriend told me he was researching ways to die I was about to pull the 9-1-1 trigger but the friend intervened as mentioned above.

I meant this less to get at useless ideas of contracting for safety and more to figure out what it means for him to have been suicidal for so long without any kind of attempt. Is he afraid that he might lose control and kill himself and has lots of intrusive thoughts? Does part of him actually want to die or not be alive anymore? What is the point of his research? Is he looking up methods of suicide to try to 'test' if he is actually suicidal? Why does he persist in treatment if nothing ever helps? Is he getting reassurance from repetitively presenting to mental health treatment? Have you done a thorough OCD inventory? Childhood history of significant anxiety?

2-Depression scales are SEVERE. Maintaining work. Lives alone that is making this also very difficult because there's no immediate people that can see him and report to me how he's doing. Next of kin are in another state. Girlfriend is in another state. When I say other state I don't mean across the river. I mean on the other side of the country.

Okay, but how is it actually impacting him apart from 'i feel lousy and think about dying'?

3-Lithium was tried. No benefit.
4-Parnate already tried, high dosages, No benefit.

High dosage meaning 40 or high dosage meaning like 90?

5-DBT skills? Already went through several therapists and he has no cluster B traits. While DBT might help and wasn't tried yet I've questioned if this should be tried given that this is not a cluster B problem.

DBT is not actually just for people with BPD, but is in fact useful for anyone struggling with chronic suicidality/dysphoria without great adaptive coping skills. It will teach him ways to live his life even if he is suicidal every single day for the rest of time.

Also answering some questions above, how much of this is his job? He does mention the job is toxic and hates it but had depression long before this job, and also has a strong family history of depression leading me to believe this is highly physiological and external situation. I already recommended he consider getting a new job but his depression is to the degree where he tells me he doesn't have the energy to find one but will stay with his current job.

Maybe ask him 'so how do you think this situation is going to change?' I think it is telling that this job makes him so miserable and he hates it and is constantly suicidal but also has no interest in changing his situation. What exactly does he have to lose at this point if he is so depressed?

Some things I haven't tried are very out of the box. E.g. Buprenorphine, Pramipexole, Amantadine.

Out of the box is what you've got now. Regardless of etiology, standard textbook stuff is obviously not going to cut it. What's his neuro exam like?

ECT? Doesn't want it and it's next to impossible to get involuntary ECT done even when the patient is hospitalized against their will

 

[clausewitz2]

At this point what is your formulation of this guy other than 'he's been depressed for a long time, is smart, and had a crappy job?'

 

[Crayola227]

Also, any other psychotropics been tried? LSD? Ayahuasca? I have a co-resident who will likely have an interesting case report involving complete remission of depression and chronic SI after a suicide attempt with LSD. Total remission has apparently continued for 6 months post SA without further dosing or medications. We've also had a few patients who regularly go to "religious" meetings to use Ayahuasca every few months for their depression who do pretty well.

I currently have a borderline patient who has been on at least 25 different meds but absolutely refuses to do therapy.

and soon Oregon will be using psilocybin.

Not sure when they will actually have their treatment centers up, but with the decriminalisation they have done I'm not sure one can't just do it there now.

I'd love to hear why that patient insists they won't do therapy.

 

[robellis]

At this point what is your formulation of this guy other than 'he's been depressed for a long time, is smart, and had a crappy job?'

hahaha damn

 

[birchswing]

I'm not suggesting this and I'm sure everyone remembers I'm not a doctor, but is there a reason not to try a stimulant? If I recall correctly, stimulants (like amphetamines) were some of the first antidepressants. Would it "activate" a person too much toward suicide if they were already suicidal?

 

[watto]

Lithium + sleep deprivation? + phototherapy?

Staying awake—the surprisingly effective way to treat depression

The first sign that something is happening is Angelina's hands. As she chats to the nurse in Italian, she begins to gesticulate, jabbing, moulding and circling the air with her fingers. As the minutes pass and Angelina becomes increasingly animated, I notice a musicality to her voice that I'm...

medicalxpress.com

 

[whopper]

Stimulants were tried. Only made him feel much more "awake." Adderall, Modafinil and Methylphenidate tried. Also no benefits in areas that would suggest ADHD. E.g. he never felt calmer, or like they cleared his head.

Parnate dosage was 60 mg. Didn't go above the FDA maximum dosage. You are right Clauswitz that we are now in the "outside the box territory" so that going to 90 mg might have to be tried although he will hate the idea of not being able to eat several types of foods.

As for the suicidal type, he's not dysphoric. If I detected any hits of self-hatred, low self esteem, fear of abandonment, irregularities with identity I would've jumped at DBT. I am still open to suggesting it but it would be more of a grasping at straws approach instead of me having any belief he has it.

Why has he hung on? I'm not sure. Family? Personal honor? He is a fall on your own sword type. HE is dedicated to keeping up with his job despite that he doesn't like it out of a sense of loyalty to his employer and I already strongly recommended he get out of the job if it is as toxic as he claims. I've seen a type of person that wants to die. He tells me he doesn't and if he did I'm convinced he already would've had an attempt (that at least he'd tell me about). IF he's into the dutiful part he likely won't want to let his parents down with committing suicide but this is getting into the touchy feely aspect where it's all speculation.

I've had patients before who wouldn't commit suicide except for that one person keeping them alive. The problem is if that person dies, well then the patient might commit suicide. It's unnerving when that one person is in bad health and could die at any moment.

We've already discussed the possibility of him literally going to Oregon for psilocybin but we both don't know anyone that as of yet could provide it. I told him if he found someone who could provide it I wouldn't be against him trying and even said if I were in his shoes I'd be open minded about it. The problem being that this is new, I don't know anyone who will emerge anytime in the near future to provide it, and couldn't vouch for it's purity or it's long-term safety.

This patient has been open to therapy but has done it for years without any improvement from it.

No neuro exam, but you know what? Still worth trying. I did refer him for an MMPI cause I told him I want no stone unturned.

 

[Stagg737]

Testosterone within normal range.

I've never detected any personality disorder, talked to his prior psychiatrist who agreed, but I referred him for personality testing just to see if there's anything I'm missing. Waiting for results.

LSD? I actually would like this to be tried but have no way to access it. I actually do think micro-dosing would be appropriate given his treatment resistance.

No TBI. No ADHD. No OCD. No formal testing but he is a very coherent interviewer. The guy's academic history is extremely impressive and he researches everything I tell him to do. If those were missed I figure an MMPI that I referred him to do will hopefully catch.

Not trying to advocate illegal use of drugs, but if your patient was willing to travel to Oregon for Psilocybin, he may be willing to travel for a new religion...

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Why has he hung on? I'm not sure. Family? Personal honor? He is a fall on your own sword type. HE is dedicated to keeping up with his job despite that he doesn't like it out of a sense of loyalty to his employer and I already strongly recommended he get out of the job if it is as toxic as he claims. I've seen a type of person that wants to die. He tells me he doesn't and if he did I'm convinced he already would've had an attempt (that at least he'd tell me about). IF he's into the dutiful part he likely won't want to let his parents down with committing suicide but this is getting into the touchy feely aspect where it's all speculation.

This almost sounds like OCPD or possibly vulnerable narcissist-like traits/features. How hard have you pushed for personality? It may not be a full disorder, but people can hide features pretty well, especially when they’re as intelligent as you say this individual is. I also have one particular patient who had a very bizarre presentation of OCPD traits, but doesn’t meet criteria for the full disorder. Would never have found it if I hadn’t spent a VERY long session with him diving into certain aspects of his “anxiety”.

 

[WisNeuro]

Curious about the ECT refusal. We get this every now and then on our gero psych unit. I'd say about half the time there are serious misconceptions about the potential side effects, and the unit attending does not do a great job explaining things. I've done a good amount of education about the cognitive piece following ECT and that sometimes puts people at ease. A couple people have actually asked about the research, which I've supplied if asked.

From a neuro perspective, sounds like this is pretty longstanding, so less likely that it's a prodromal symptom of a neurological disorder. Rare chance it's a space occupying lesion like a meningioma.

 

[clausewitz2]

So. If he's not dysphoric, and still does his job just fine, doesn't want to die, has never attempted, is maintaining a romantic relationship, and is supporting himself, what does it mean to say he is depressed? Is he just having unwanted intrusive thoughts about suicide that he doesn't actually like or want to act on? Does he just feel he shouldn't be having these thoughts and that's the distress? He's unwilling to do anything significant apart from medications (engage in therapy for a prolonged period of time, do ECT/anything interventional, find a different job), so what does his current behavior pattern do for him? I know that you think this is the "touchy-feely" bit but I think it's crucial to understand what is going on.

Usually people who score severely on depression scales are also not doing well in some part of their life to the extent that an outside observer would say "yeah, things aren't going great for them." We have someone who is producing verbal behavior leading to severe scores on those scales but what concrete impact is that having on him if he doesn't want to die, isn't dysphoric, isn't self-harming, isn't attempting, and isn't having trouble carrying out his expected social roles?

Because if it's really just a sense that he's not as happy as he "should" be, an acceptance-focused approach may be in order.

 

[dl2dp2]

I think he has a personality disorder. LOL The main sign is refusal for ECT.

I suggest a course of TFP.

As to liability, if you document well and have a good relationship with the family, I don't see any liability. You can't just lock someone up because they are chronically suicidal with some fantasies without intent or a concrete plan. Document consistently as such.

 

[whopper]

Romantic relationship ended, but the ex-girlfriend is still a friend.

ECT: Doesn't want to do it because he has an intellect-heavy job and worries it'll mess him up at work. The guy (and I'm intentionally not trying to give out his specific details) has a type of job that required graduate education and he went to elite institutions.

Also, I don't sense any personality disorder characteristics. E.g. he's always been polite to me, my assistant, the prior doctor and all of his staff. His family and friends describe him as a nice and dependable person. Again could be he does have something there but I'm not detecting it. Still waiting on an MMPI.

 

[clausewitz2]

Romantic relationship ended, but the ex-girlfriend is still a friend.

ECT: Doesn't want to do it because he has an intellect-heavy job and worries it'll mess him up at work. The guy (and I'm intentionally not trying to give out his specific details) has a type of job that required graduate education and he went to elite institutions.

Also, I don't sense any personality disorder characteristics. E.g. he's always been polite to me, my assistant, the prior doctor and all of his staff. His family and friends describe him as a nice and dependable person. Again could be he does have something there but I'm not detecting it. Still waiting on an MMPI.

So this is still totally consistent with Cluster C and is actually pretty typical of people who are over-controlled. One can be polite and agreeable and still have a PD.

So he hates his job but also it's worse for him to miss some work than to potentially be less depressed? What happens when you bring his attention to this tension?

 

[splik]

Also, I don't sense any personality disorder characteristics. E.g. he's always been polite to me, my assistant, the prior doctor and all of his staff. His family and friends describe him as a nice and dependable person. Again could be he does have something there but I'm not detecting it. Still waiting on an MMPI.

What does this mean? You don't think patients with personality disorders can be nice? Even if he doesn't meet full criteria for a personality disorder, you are describing some masochistic features. He won't try ECT or consider some other brain stimulation therapies, won't consider taking medication combinations different to but made of drugs hes tried before, he won't give up a job that makes him miserable, he hasn't responded to multiple trials of medications, therapy, and TMS. You have to consider that he cannot allow himself to get better or believes that he has to suffer. The suicidal preoccupations sound obsessional like an undoing defense. Barring some underlying neurometabolic disturbance like cerebral folate deficiency you must consider personality disturbances because he has been treated for depression and those treatments have not helped.

 

[WisNeuro]

Romantic relationship ended, but the ex-girlfriend is still a friend.

ECT: Doesn't want to do it because he has an intellect-heavy job and worries it'll mess him up at work. The guy (and I'm intentionally not trying to give out his specific details) has a type of job that required graduate education and he went to elite institutions.

Also, I don't sense any personality disorder characteristics. E.g. he's always been polite to me, my assistant, the prior doctor and all of his staff. His family and friends describe him as a nice and dependable person. Again could be he does have something there but I'm not detecting it. Still waiting on an MMPI.

Sounds like he suffers from the misconceptions. Or maybe he's assuming the short-term effects will become long-term?

 

[nrmp]

The easy way out is for me to terminate him. I won't have to deal with the legal repercussions of keeping a difficult patient. That will entail him getting a new psychiatrist who will have to start all over. Further, and let's be frank, lots of psychiatrists only spend a few minutes with patients. I am confident he will likely not get care as good as I can provide.

As of this time I will not terminate him because I believe doing so is pretty much the coward's way out and I'd only be doing it to save my own butt and not out or regard for him.

I did refer him to treatment resistant clinics. One of the best in the nation is in my area. I also referred him to institutions that specialize with highly regarded treatment and quality such as the Lindner Center and the Meninger Clinic. Also he's been seen by 2 other doctors in the area who are considered top in the field who also couldn't get him better.

IOP in my area I have no confidence cause I've already seen too many try this and they told me the psychiatrist saw them for 5 minutes and they were simply in group therapy all day that wasn't specific to their problem.

This is really a zone where I don't like it. I actually don't mind having a patient that's doing bad and needs a lot of intense effort. I mind the possibility that if the guy kills himself a legal armageddon can happen despite that I am doing above the standard of care and could take years to resolve.

I support to continue your above the standard of care and not terminate. It's chronic suicidality and where I would document that based on risk analysis there are no particular modifiable risk factors at this time. Though patient remains high risk, I strongly believe short term inpatient hospitalization won't change the coarse of illness. I believe I have few similar cases in my practice and if you at their phq-9 for last few years they are like always >21.

Have you tried stimulant or Deplin? Just a thought..

 

[whopper]

What does this mean? You don't think patients with personality disorders can be nice?

Of course they can be. And they can also be too nice. The point I was making was I didn't see any hard signs of any personality disorder. Also he had reasons to not get out of the job he doesn't like (that I didn't mention before) such as he doesn't know how easily he could get a new job because of the pendemic.

you are describing some masochistic features

Yes, although the term technically involves enjoyment from being abused. There's no enjoyment on his part but I think I get your point.

Have you tried stimulant or Deplin? Just a thou

Yes to both. No success with either. A pharmacogenetic test did show he was an intermediate metabolizer with L-Methylfolate. Already tried L-Methylfolate and no success.

 

[Mr. Nightmare]

What about sending him to a Day Treatment Center? It sounds like he may need a higher level of care.

 

[Stagg737]

Romantic relationship ended, but the ex-girlfriend is still a friend.

ECT: Doesn't want to do it because he has an intellect-heavy job and worries it'll mess him up at work. The guy (and I'm intentionally not trying to give out his specific details) has a type of job that required graduate education and he went to elite institutions.

Also, I don't sense any personality disorder characteristics. E.g. he's always been polite to me, my assistant, the prior doctor and all of his staff. His family and friends describe him as a nice and dependable person. Again could be he does have something there but I'm not detecting it. Still waiting on an MMPI.

Two things I would want to know, how much collateral have you gathered? It seems like you've talked to someone because people have said he seems pleasant and normal at times, but have you done a really thorough history of symptoms with anyone really close to him? "Aha!" moments frequently come from outside of the normal patient-doctor relationship, and while I've had far more of those on the inpatient side of psych I have had one or two moments like that this year when parents or spouses reported something the patient either didn't admit to or just didn't think was relevant that completely changed the treatment course (for the better, usually).

Possibly the most important question that I haven't seen explicitly asked is "What are your goals for treatment?" Are you trying to find a way to resolve his SI? Improve his depression based on scales? Subjective improvement of depression? Provide a more solid diagnosis?

It's an interesting case and thank you for sharing, but what exactly are the goals for this patient other than be less depressed? Some patients do well just going off how they feel, others need concrete goals, others need to be directly told they're never going to be "normal" but that they can be in a better place that looks like _____. Idk how long you've had this patient or how extensively you've talked about this with him, but revisiting the goals of treatment may provide some benefit on its own.

Side question: What are this guy's personal beliefs like? Nihilistic? Utilitarian? Religious? Given family history, I would rule out a biologic factor, but clearly with that many med failures there's at least some cognitive aspect to this that is preventing him from from really doing well. I'm also assuming there's no possibility that this guy is on the very high functioning end of the (autism) spectrum?

 

[FatherPsychiatry]

I'm also getting a sense there's a bit of idealization of this patient happening...

 

[dl2dp2]

Romantic relationship ended, but the ex-girlfriend is still a friend.

ECT: Doesn't want to do it because he has an intellect-heavy job and worries it'll mess him up at work. The guy (and I'm intentionally not trying to give out his specific details) has a type of job that required graduate education and he went to elite institutions.

Also, I don't sense any personality disorder characteristics. E.g. he's always been polite to me, my assistant, the prior doctor and all of his staff. His family and friends describe him as a nice and dependable person. Again could be he does have something there but I'm not detecting it. Still waiting on an MMPI.

I feel like this is fairly classic cluster C, with some narcissistic traits. I have a number of patients like this, with varying degrees of "suicidality".

Take ECT out of the equation. Let's say that ECT also doesn't work. What's your next step? This patient is actually a very good candidate for intensive insight-oriented psychotherapy. MMPI will be useless IMO. He needs to make a commitment of 2x/week therapy with you for 6-12 months with very strict frames. In my experience, this type has a turnaround in about 1-2 years minimum. You didn't give age but I assume late 20s to early 40s. "Success" (as in the resolution of many of the most critical symptoms) is about half and half--higher with younger patients. I do better with combined therapy. Remember this patient is MED FREE essentially right now. I've done this with several patients where they are either med-free or only with a touch of fluoxetine.

If you see him 2x/week you won't be worried he'll kill himself. You'd be closer to him than his next-to-kin. The type of therapy is of secondary importance, but there are several manualized on the market: TFP, Schema, etc.

I'm also assuming there's no possibility that this guy is on the very high functioning end of the spectrum?

As per above, this guy is EXACTLY the "very high functioning" but still "hates his job" type that I see daily. They are also often "loners" who aren't good in relationships (for obvious reasons). The main cause of suicidality is "existential" and unrealistic and narcissistic expectations of perfectionism in life. Refusal for ECT for work is not sensical. If he's really up for killing himself what does it matter if he takes a month off--especially because he's single has no family commitments? The story makes no sense.

I also feel like the countertransference here is apparent. It's easy to get rid of this person without "doing him wrong": you refer him to the local academic medical center for a "consult" as you admit to yourself and to him that you don't know what to do with him. But the physician insists that if he can just figure out "the right medication" it'll all go away, but since he can't he's stuck in the impossibility of liability and inadequacy. Notice the value-laden, ultra-personal descriptions ("cowardly", "thinking more about yourself", "he will likely not get care as good as I can provide." etc.). Classic projective identification. I would re-read the "almost untreatable patient". He wants you to be the failed parent, and it sounds like you already do--you like him and don't want him to be a "PD patient", but yet feel hopeless--the technically "correct" thing to do as per both TFP and Schema is to roll with this and BECOME his parent.

 

[watto]

I feel like this is fairly classic cluster C, with some narcissistic traits. I have a number of patients like this, with varying degrees of "suicidality".

Take ECT out of the equation. Let's say that ECT also doesn't work. What's your next step? This patient is actually a very good candidate for intensive insight-oriented psychotherapy. MMPI will be useless IMO. He needs to make a commitment of 2x/week therapy with you for 6-12 months with very strict frames. In my experience, this type has a turnaround in about 1-2 years minimum. You didn't give age but I assume late 20s to early 40s. "Success" (as in the resolution of many of the most critical symptoms) is about half and half--higher with younger patients. I do better with combined therapy. Remember this patient is MED FREE essentially right now. I've done this with several patients where they are either med-free or only with a touch of fluoxetine.

If you see him 2x/week you won't be worried he'll kill himself. You'd be closer to him than his next-to-kin. The type of therapy is of secondary importance, but there are several manualized on the market: TFP, Schema, etc.



As per above, this guy is EXACTLY the "very high functioning" but still "hates his job" type that I see daily. They are also often "loners" who aren't good in relationships (for obvious reasons). The main cause of suicidality is "existential" and unrealistic and narcissistic expectations of perfectionism in life. Refusal for ECT for work is not sensical. If he's really up for killing himself what does it matter if he takes a month off--especially because he's single has no family commitments? The story makes no sense.

I also feel like the countertransference here is apparent. It's easy to get rid of this person without "doing him wrong": you refer him to the local academic medical center for a "consult" as you admit to yourself and to him that you don't know what to do with him. But the physician insists that if he can just figure out "the right medication" it'll all go away, but since he can't he's stuck in the impossibility of liability and inadequacy. Notice the value-laden, ultra-personal descriptions ("cowardly", "thinking more about yourself", "he will likely not get care as good as I can provide." etc.). Classic projective identification. I would re-read the "almost untreatable patient". He wants you to be the failed parent, and it sounds like you already do--you like him and don't want him to be a "PD patient", but yet feel hopeless--the technically "correct" thing to do as per both TFP and Schema is to roll with this and BECOME his parent.

Yeah, didn't you say the mother was chronically depressed? No surprise that he has this profile. Never could make his mom happy. Can't make you happy, either. Or any of the providers.

 

[clausewitz2]

Five gets you ten that the minute you breathe a word about sending him for a consult you see approximately 1000x more emotion than you have so far in working with him. Probably in the form of a rambling email/voicemail.

 

[Stagg737]

As per above, this guy is EXACTLY the "very high functioning" but still "hates his job" type that I see daily. They are also often "loners" who aren't good in relationships (for obvious reasons). The main cause of suicidality is "existential" and unrealistic and narcissistic expectations of perfectionism in life. Refusal for ECT for work is not sensical. If he's really up for killing himself what does it matter if he takes a month off--especially because he's single has no family commitments? The story makes no sense.

Just to clarify, I was poking at the possibility that this guy is on the very high functioning end of the autism spectrum. I realize it's way out there, but sounds like almost everything else has been or is being worked up, so why not?

 

[sloop]

My feeling with patients like this has been that you just have to do your best and thoroughly document your decision-making.

With regard to the liability, I won’t pretend that a family can’t find some hired gun to support a negligence claim, but that will almost always be the case so it’s barely worth considering.

It does not seem like you think hospitalization is clinically appropriate as you don’t think it would achieve anything. Terminating the patient does not seem ethical to me unless you legitimately feel you have nothing left to offer them and that someone else could offer more. To me, it seems like all you’re left with is continuing to do your best and making sure you’re the documentation tells a story of a thoughtful, committed psychiatrist who is doing his best for a difficult patient. I imagine that, in most cases, that should be enough to defend any negligence claim. If not, that’s why malpractice insurance exists.

 

[dl2dp2]

Just to clarify, I was poking at the possibility that this guy is on the very high functioning end of the autism spectrum. I realize it's way out there, but sounds like almost everything else has been or is being worked up, so why not?

I realized that I misread. That said, in my experience, there's a big overlap between "high functioning autism" and cluster C+narcissism. I almost think that they describe the same phenomenon using different language. The difference is between being unable to process social information vs. being UNWILLING to process social information. What if you are unwilling to make the EFFORT to process social information because it's HARD for you to do? How would you know?

Assuming that you use some gold standard instrument and diagnose his autism (ADOS etc), what's the difference in treatment? Social skills training? But at the end of the day a major focus of long term therapy for personality disorder per se IS social skills training...The real game here is the FRAME of the treatment, not the content. You want him to commit to get better with you both literally and figuratively.

 

[birchswing]

Everything I've read has been so compelling that I hesitate to add the couple of oddities that came to mind:
Does he take any other medications? Something like Propecia or any frequent or long-term antibiotic use? Another out-there thought since you covered so many bases is celiac. I know it usually wouldn't present with just psychiatric symptoms, but it's possible.

 

[psychacad]

What;s your sense of the severity of the depression? The fact that he was discharged in 3 days tells you a lot, and it would be interesting if you get hold of what the inpatient team observed (edit: I see, he may not have been hospitalized yet, but even the fact that you think he will be discharged so quickly tells you you're aware on some level that he's not really that depressed).

Weight loss? Eating habits? Psychomotor ******ation? Sleep journal? Anhedonia? (i.e what is he doing in his spare time).

I feel like collateral is crucial in these cases. For someone who appears to be this functional, severe clinical depression makes it less likely, regardless what he fills on the scale. In other words, try to get more objective sources of information.

This does seem so far a more 'personality' case even if he doesn't check the box for one of the personality diagnoses on the DSM. Therapy might work better and throwing more meds and procedures on this could be counterproductive. We've certainly seen the 'nothing you do makes me better' type. Does not mean it is actually true, which is why it's critical to try and find some source of objective information.

On another note, having been tangentially involved in some of the 'treatment-resistant depression' research, this is a frequent source of frustration. Patients who appear to meet the criteria based on whatever score they get on the scale but perhaps they are really talking about unhappiness rather than severe clinical depression. This is where it is important to use your judgement, and objective markers of depression (weight loss, functionality, psychomotor ******ation, longitudinal observation by others) are really important.