Treatment Resistant Depression–Under Recognized and Under Treated

As a psychiatrist . . . as an empathic person . . . it is very difficult to hear stories like the one listed below:

My heart is broke and i Feel I will never leave this deep black dark hole that I cant escape… Im tearing up heavily as I write this message… Ive been on 50 different types of medications it feels like the past 4 years and im only 25…. no one understands… and as much as they think they do.. they dont….. I am taking myself off all my medications by weaning myself off… there is no point in being on them and still experiencing all the symptoms that i would as if i was not on them.. I feel defeated,, my only hope is in jesus christ, some sayy well its a chemical imbalance and I know it is, but i cant take these meds anymore.. i have failed over and over, though Im not giving up it seems failure still follows right behind me. with poor commitments , poor job history, poor relationships.. Im seriously heartbroken…………

Treatment resistant depression is a crushing illness for those people unfortunate to experience it.  People with seriously debilitating medical illness can still take solace from friends, family, activities, etc.  Not so if you have severe unremitting depression.  You feel very, very alone, and you tend to push people away so, for many people with this illness, you really are alone.  I have yet to hear of a “Beef and Beer” being thrown to help encourage and support someone with psychiatric illness.

The numbers for depression are staggering.  In a study done in 2003, Kessler et al. found that 14 million adults in the us experience an episode of Major Depression.  Of those, only about half (7.2 million) received treatment.  Of that 7.2 million who received treatment, only 3.2 million received adequate treatment.  If you extrapolate data from the STAR*D study (that is the “Sequenced Treatment Alternatives to Relieve Depression” study–the nation’s largest depression treatment study) to this population, you get some scary numbers.   In the STAR*D study, only 67% of the patients reached clinical remission.  So, by those estimates, 67% of 3.2 million . . . or 2.1 million . . . got better.  Roughly 2.1 million out of the 14 million US adults who get depression receive adequate treatment and respond to that treatment.  That’s 15 %.  Pitiful.  Can you imagine the outcry if only 15 % of the 23 million adults with diabetes got adequate control of their symptoms.  Or if 15 % of the 1.5 million victims of heart attack reached remission of their symptoms.  It would not be tolerated.  With mental illness, however, the silence is deafening.  This lack of attention and lack of adequate treatment is why Major Depression is expected to be the second highest cause of human disease burden worldwide by 2020.

So, what are our options?

1.     Clearly we who experience or treatment mental health issues must stop being embarrassed by the illness and stand up for recognition and adequate treatment.  With the current battles going on in Washington, DC about health care, how many of you have contacted your Representative or Senator to urge them to make adequate mental health coverage mandatory?  If not, go to www.usa.gov and click on “contact elected officials” and let them know how you stand on this issue.

2.     Get yourself educated.  Or, if you cannot because of your illness, get a family member to be your advocate for you and attend some of your doctor’s appointments with you if at all possible.  The mental health system in this country is not good and you have to be savvy and on top of your treatment.  People bring family members to appointments regarding cardiac issues, diabetes, and irritable bowel disease all the time . . . because they need the support and the guidance.  Having an educated  someone go with you to the med check or evaluation can be equally vital to treatment.  If the doc is not willing to allow that . . . get a different doc.

3.     Make sure your med trials make sense.  Remember those numbers at the top of this blarticle????  Of the 7.2 million people who got treated, 4 million . . . more than half . . . received inadequate care.  It is vital that depression be aggressively treated.  One of the main causes of treatment failures is not getting enough medicine for long enough.  That can be from intolerable side effects or it can be from inadequate prescribing.  The end result is the same . . . persistent symptoms of depression.

4.     Use of adjunctive agents.  More and more, combination pharmacotherapy is able to help patients achieve improvement in their symptoms.  That can be innovative combinations of antidepressants or addition of augmenting agents such as lithium, thyroid hormone or second-generation neuroleptics.  Again, the more educated you can be, the better you will be to discuss these options with the doctor.

5.     Do all the right things . . . eat right . . . get enough sleep . . . exercise . . . pray or meditate . . . stimulate your mind . . .

6.     Get yourself a good therapist that is going to listen to you . . . work with you . . . and kick your butt when you need it kicked.  Too often we allow ourselves to fall into a pattern of negative behaviors that promotes our depression.  It takes a great deal of courage and a great deal of help to confront those patterns.  A good therapist is worth their weight in gold.

7.     Innovative approaches.  When all the right things are done . . . some people continue to have significant symptoms of depression.  For that population, we would, in the past, prescribe ECT.  That can work well for some, but can have very significant consequences for others with long term cognitive issues.  It is also a time-consuming and potentially hazardous invasive medical procedure.  But it was all we had until . . . Vagus Nerve Stimulators.  That was a bust, as far as I am concerned.  I tried to get several patients approved for it without success.  And the cost was prohibitively high (tens of thousands of dollars for the procedure) and the outcome was still questionable.   And it was very invasive (wrapping an electrode around your vagus nerve and implanting a pacemaker-like stimulator in your chest).  And NOW . . . . . . . . . . . we have TMS . . . Transcranial Magnetic Stimulation . . . which has been present in Canada and elsewhere for years, was approved by the FDA for a company called Neuronetics which developed a TMS system that proved effective for the treatment of Major Depression that did not respond to one adequate trial of an antidepressant.  More on that another time.

So, to the writer of the letter above, I do not know what the quality of your treatment has been . . . but my guess is that there continue to be other options available for you, but you must be open to these options . . . and you may need to get yourself some help in attaining these options.  My thoughts and best wishes go out to you.

–Dan Hartman, MD