Reviewing Treatment Plans for TRD

This post is inspired by a recent post on the Dr Shock MD PhD blog. The post titled: "Management of Depression" brought up a number of issues that I generally discuss with my pdoc, but also a couple I avoid because I am scared. Each of the nine section titles below are taken directly from Dr. Shock's article.

He talks about: "...the components of a comprehensive management plan and factors associated with increased risk for recurrence of depression". I found the article very interesting and I'm bringing it to my therapy session tomorrow to thoroughly discuss my treatment plan with Dr. X.

Being the inquisitive person I am I have discussed much of this with him already, but I think the information Dr. Shock posted about the "[c]omponents of a comprehensive management plan for depression. Adapted from American Psychiatric Association and World Federation of Societies of Biological Psychiatry guidelines" is a really comprehensive list of discussion points.

I will try to relay how they relate to me, my treatment plan, and my continuing difficulties working to find a solution to not simply Treatment Resistant Depression, defined as resistance to at least two medication trials...but a depression that has consumed me for years and been resistant to more than 30 medications and years of therapy:

1)"Determine the pharmacological or psychosocial treatment":
I've tried (numerous times) different CBT therapy treatments, Group therapy (twice), individual therapy(with numerous different therapists). I think my current supportive therapy has "saved" my life. I believe it gives me the strength to keep trying in the face of continued failure.

I feel I have a very valuable therapeutic alliance with my pdoc, stronger than any I have ever had with any therapist I have seen. I do, however, often question the value of continuing as it really has not put a dent in my depression. I wonder sometimes if I should try another therapist, but I have seen at least 7 or 8 different therapists since I began having depressive episodes at 17 or 18.

The therapy I am involved in now is better than any of them and some of the therapists I saw were so awful I do not even know how they remained to do what they do. So I really feel like I am in a better situation right now despite not making much progress. I feel safe, can talk about anything, feel advocated for and supported by my pdoc 100%.

• Pharmacological treatments have been completely unsuccessful to date despite trying 30 plus medication alone, in combinations and using augmentation. This is so frustrating and I feel like it has to be my fault. Why do others get better, when I feel like I try so hard and never seem to succeed?

2) "Determine the treatment setting": I assume this means outpatient/inpatient/day program etc. My pdoc tried numerous times to get me into the hospital last spring/summer. I seemed to go into an up phase, just as I was about to concede so decided against it. He suggested maybe a hospital stay would allow a second opinion. Problem is I have had second opinions two other times before and both of them said I had Bipolar Disorder. My pdoc says I am somewhere in between Major Depression and BPII. I get what looks like hypomania, but it does not impacts my life in any negative way...so he believes I sit somewhere at the end of Major Depressive Disorder and at the beginning of BPII.

It doesn't really matter because our we have used treatment approaches for both illnesses and somewhere in between and still we have not had success. To me, and to my pdoc, diagnosis is a means by which we develop a treatment plan and I trust fully that that is being done. My pdoc has experience working in a mood disorders program, and I feel confident in his skills.3)

3) "Establish and maintain a therapeutic alliance": I feel this is perfect and could not be better.

4) "Monitor and reassess the patient’s psychiatric status in the course of treatment": This is a question I would like to ask my psychiatrist. How do you monitor and reassess my psychiatric status over the course of the treatments we try? I sometimes feel like we stop trying medications too soon, or that we may miss an opportunity for a combination to work even if a particular medication is not working. Eg. Now I am going off Tegretol...my concern is that I feel it has helped me a tiny bit "sometimes", and I understand the treatment of TRD and/or BP disorder generally utilizes a mood stabilizer. I have no side effects with Tegretol and really would like to keep trying to find something that works with it.

5) "Monitor the patient’s response to treatment"...this seems like the same as above. No?

6) "Reassess the adequacy of diagnosis when appropriate": This is a biggy for me. I have often asked my pdoc if maybe I have a personality disorder; especially Borderline Personality Disorder, given my fears of abandonment and all my suicidal thoughts. Dr. X has told me numerous times that he, "...has not even considered BPD as a diagnosis for [me]".

He is however, cryptic sometimes when I bring up the question of whether or not I have a personality disorder. For example, one time I asked him if I had a personality disorder and he asked me, "what would it mean to you to have a personality disorder?"

I am not a psychiatrist so I had no idea what to say, except maybe it means I have a pattern of behaviour that is embedded so deeply in who I am and that is why the medication is not working. I have asked him if he would be honest with me if I had a personality disorder. He said he believes that honesty is very important and that he would not hold back information from me. Given how trustworthy he has proven to be over the years I have to believe he is being upfront with me, but I have this niggling feeling that something beyond a mood disorder is impacting my ability to become well.

7) "Monitor possible side effects and physical condition": I used to keep a daily mood calendar tracking mood, irritability, anxiety, exercise, medications, side effects, etc. A couple years ago I began feeling like maybe my micromanaging of my symptoms what keeping me sick so I stopped doing it. I go into my appointments with less clear information than before, and I often forget to tell my pdoc things. So not sure if I should begin my mood charts again.

I did ask my pdoc last week if maybe we stop medications too early because of side effects and don't give my body enough time to work through the side effects. He said maybe sometimes we have done that, but many times it becomes really clear that the side effects are unmanageable, or that the small benefits the medications give me are not enough for me to suffer the side effects. I almost always want to keep trying a medication longer even if it isn't working, because I am afraid I might miss out on that time when they might begin helping me. Usually we decide together.

8) "Enhance treatment adherence": I always take the medications Dr. X. and I decide on. I am not one to just go off my medications and not tell him. I do understand that I have some problems that may impact the medications working as well:

• With Benzodiazepines I find they help with my anxiety at first, but then I sometimes (not always) begin increasing them slowly because they stop working. I recognize their is a fine line between controlling anxiety and perhaps inducing a worse depression because I am too fatigued to do anything. Recently I was told to increase my Diazepam to 20mg (from 10mg)...I tried it a couple days and decided I did not want a repeat of last summer where I came of a fairly high dose of Diazepam and ended up have severe rebound anxiety and insomnia (for 3 months last time). I always inform my pdoc when I increase or decide against our plan though. How can he treat me properly if he doesn't know what I am taking?


• This is so hard to write and for some reason I feel so ashamed for being weak like this...I rarely talk about it, except with my pdoc)...When my Mom was diagnosed with pancreatic cancer I moved in with her to help her. I was so depressed, and on top of that grieving, and I began to drink to help numb all my feelings. Honestly, with no medications working it was the only thing that helped. I recognize now that I have had alcohol problems intermittently throughout my life, since I was 13. I have gone years without drinking hardly anything, maybe a drink here or there, once in a blue moon, but there have also been years when I was stressed out that I have been a binge drinker, starting with my high school years. Anyways, since my mom's death I have struggled with alcohol and I know that has impacted my wellness and made my depression more difficult to treat. In the last year I am really trying hard to change that, and I believe slowly, I am getting there.

9) "Educate patients and their families about the nature of the illness (psychoeducation)": I feel I am very educated about my illness, but I still have not accepted it. I'm not sure if I ever will be able to. Despite believing others like me are ill, and have a bonafide illness I continue to feel intensely guilty for not being able to work, for having an almost impossible time getting motivated to do things, for many things that my pdoc has taught me are "symptoms" of depression.

I also know that it would really help me if my family, my husband, my sisters, and my dad, would learn more about Major Depression, and especially about Treatment Resistant, and/or Chronic Depression. My pdoc likens my husband's negativity to medications to a "negative placebo effect" My husband rails so much about medications hurting me as opposed to helping me, that his insistence in this area could very easily impact the ability of the medications to help me. I really believe in the medications, so I am pretty sure I override his negativity, but you never know. The rest of my family seems to think I should just go see a naturopath and I'd get better, or I'd miraculously get better if I just got a job. Wouldn't that be great? I find their being unsupportive of the therapy I have decided on to be so frustrating. I wish they would come to a few therapy sessions with me, but that just isn't going to happen.

I do not even want to think of the "[f]actors associated with increased risk for depression recurrence." as listed on Dr. Shock's blog, because I have every single one. I cannot afford to focus on whether my depression will recur, until I can manage to get rid of the episode I am currently in.