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For this week’s episode of Hardcore Self Help, I’m talking about when you just can’t get rid of depression. You’ve had depression for a long time and you’re sick of it. You’re tired of feeling exhausted, upset, irritable, and hopeless. Maybe it’s even gotten to the point that you have seen a therapist and agreed to take psychiatric medication. Maybe you’ve even been hospitalized because of it. Despite your best efforts, though… the depression still lingers. It still holds you back and you just can’t seem to shake it the way that the books say you should be able to. I know it’s frustrating, but there is hope still. In this post, I will talk about some options when the normal interventions don’t seem to work and you just can’t get rid of depression.

So, what can you do when you just can’t get rid of depression?

Lifestyle Changes

You use medications to find a more favorable balance of neurotransmitters in your brain, or find new ways of challenging your negative thoughts. But none of that is going to do a damn thing to change the circumstances of your life. If you are in a situation in your life that is constantly negative and draining, that is going to contribute to depression, even if you are doing your due diligence with treatment. So if it feels like you are fighting an uphill battle and doing all of the things that you are supposed to be doing to recover from depression and it’s not working, you may need to consider whether there is something in your life or environment that needs a radical change.

For instance, if you are in a job or a relationship that is constantly causing you distress and sadness, it might be time to make a shift to something new. If you are living with family members that are toxic and cause you to question your self-worth, it may be time to get some distance from them. On the flip side, if you are trying to live independently and realize that isolation and the responsibilities that come with living on your own are too immense, it may be worth getting a roommate or moving in with family that can help out. These lifestyle changes aren’t always easy. Sometimes you can be really stuck due to finances or other circumstances, so you may need to be creative and enlist help to make these changes.

Medication Changes

We are very lucky that we live in a time where there are medications that can help ease the burden of mental illness. However, psychiatric medications are blunt instruments and unfortunately there is no solid way for us determine ahead of time which exact medication is going to be the perfect one for you. We can narrow it down to broad categories given your history and symptoms, but from there it can take a bit of trial and error. People respond differently to medications. Sometimes a person will not respond or will have massive side effects from a particular medication, but respond super well to a different medication within the same class. Our bodies are just weird like that.

So if you are taking medication for your depression, but it does not seem to be helping, you may need to try a different kind of medication. For this reason, I often suggest going to a psychiatrist rather than your primary care physician to get your psychiatric meds. A psychiatrist is a medical doctor who focuses exclusively on treating psychological disorders. That means that they are going to have a greater awareness of the different medications that are available and will have much more experienced and specialized training than your general practitioner. Whether it’s trying a different medication in the same class, adding on an additional medication, or switching to an entirely different class of medications, your psychiatrist will be able to advise you and guide you through that process.

Try a Different Therapist

As psychologists and therapists, we go to school for years to learn about how to best treat mental disorders. We learn lots of techniques and principles that are supposed to help us help you change. The funny thing is, all of those fancy techniques are only part of the puzzle. It turns out that factors like your expectations for therapy (do you believe it will help?) and your fit with the therapist (do you get along as people) also make a big difference in whether you are able to change. If you find that you and your therapist do not click, you feel inappropriately judged, or you don’t feel that they have the skills to help you change, don’t be ashamed of finding someone new to work with. If you are in a care network and they give you the impression that you aren’t allowed to switch providers, that’s usually bullshit. You have the right to see someone that fits.

Options for Treatment Resistant Depression

If you have participated in therapy, tried medication, and tried all of the tips that I listed above and you are still crushed by strong depressive symptoms and/or suicidality, you may have something called “treatment resistant depression”. This is when you have intense depression that does not respond well to the typical treatments. There are a few different types of treatments that are specifically helpful for people with treatment resistant depression.

Electroconvulsive Therapy

When people think of electroconvulsive therapy (ECT), they tend to imagine the stuff of horror movies, almost like the electric chair. This is for good reason. We have known that passing electrical current through the brain can have a positive impact for certain mental health issues for a long time. However, in the past, higher doses were administered in less regulated, more dangerous way. These days, it is done in a hospital setting under general anesthesia. You are closely monitored and smaller electrical current is used.

The result is that ECT intentionally triggers a brief seizure that causes changes to brain chemistry that can quickly impact the symptoms of certain mental illnesses. It works particularly well for treatment resistant depression but it is also used for other issues. It can also be used when medications are not tolerated or would not be appropriate such as in older adults or pregnant individuals.

In general, ECT is quite a safe procedure. It can have some side effects such as memory loss for the time surrounding the treatment, headaches or other pain, and confusion immediately following treatment. In the majority of cases, these side effects are temporary and diminish relatively quickly. Obviously if you have a medical condition like heart disease, this may not be an appropriate treatment for you.

The way it actually looks is that you will be given an IV for fluids and medications and then electrodes will be placed on your head. ECT can be administered to one side of the brain or both, depending on the case. You will be placed under general anesthesia so that you don’t have any conscious awareness of the procedure and you will be given a muscle relaxant to help prevent injury and reduce the impact of the seizure. You will also likely be hooked up to other monitors such as blood pressure and heart rate to ensure that you are tolerating the treatment well and you may be given a rubber guard for your mouth to prevent any injury to your teeth or tongue.

The seizure itself usually lasts less than a minute and you don’t convulse violently since you are under anesthesia. In the US, ECT is usually administered in a sequence. Typically, you will go two to three times per week for a few weeks in a row, resulting in a total of 6-12 treatments. Interestingly, we don’t actually know why ECT works. We simply know that the seizure causes changes in the brain chemistry that help people rapidly change. Most often continued use of antidepressants and/or therapy is still indicated to maintain the changes that have occurred.

Transcranial Magnetic Stimulation

Some people do not like the option of ECT due to the fact that it is somewhat high impact. You wouldn’t necessarily be able to function at work or school for at least a day after a treatment and having multiple sessions per week can be quite intrusive. Luckily, there is another option that is somewhat similar that may also provide relief for treatment resistant mental illness. It’s called transcranial magnetic stimulation (TMS). If you break that name down, it really is exactly what it sounds like. They use a magnet, passed over the outside of your skull, to stimulate your brain.

TMS is a non-invasive procedure and it is much more low-impact than ECT. A magnetic coil is placed against your skull and delivers a harmless magnetic pulse to stimulate specific regions in your brain. Just like ECT, TMS seems to be particularly effective for depression that has resisted other forms of treatment. Generally the side effects are quite mild and might include headache or pain on the scalp where the magnet is placed. In some cases it can also cause minor facial twitching or lightheadedness.

TMS does not require anesthesia and is low impact. In most cases, people are able to resume their normal daily activities immediately following a treatment. The first session is usually a bit longer, but the remainder of sessions will run about 40 minutes. TMS does require quite a few sessions to have an effect. often it requires people to go in 5 days per week for a month or more. However, the results are promising and many people with treatment resistant depression see a significant increased in mood and functioning after going through a course of TMS.

It is a relatively new procedure and there is some variability in technique between clinicians. As time goes on, best practices for administering it will be more extensively researched. However, don’t let that scare you. It’s a non-invasive procedure with very few side effects, if any, for most people. The main sticking point is that it takes a lot of time.

Ketamine Infusion

There are a variety of substances that the US government has identified as dangerous due to their recreational use that actually seem to have a lot of promise when used therapeutically for mental health issues. Ketamine is one of these substances. Ketamine is a medication that provides pain relief, sedation, and a trance-like state. It became popular for recreational use as a rave drug in the 90s, prompted the government to crack down and list it as a controlled substance. It is currently used in a variety of medical contexts as a sedative to start anesthesia but it turns out that it is also very helpful in helping with treatment resistant depression.

Ketamine works by increasing the activity of a neurotransmitter called glutamate. This is an entirely different mechanism of action from typical antidepressants, which tend to act on serotonin or norepinephrine. The result is that it acts very quickly and bypasses the processes that usually cause antidepressants to take several weeks to work. This treatment causes nearly immediate results and has been shown to effectively alleviate feelings of hopelessness and, in some cases, suicidality. While there is some degree of immediate relief, you will most likely be administered multiple treatments over the course of a few weeks to ensure lasting change. In some cases, you may also come back in for periodic maintenance treatments.

The side effects are relatively mild. While you are receiving the treatment, you may be in a trance-like state and feel somewhat dissociated from your body. You may also have some degree of nausea or headache, depending on how well your body tolerates the substance. In general, it appears to be a very good option for people with treatment resistant depression and carries relatively little risk.

Other Substances

There are also other substances that have been shown across history to have therapeutic uses in a variety of cultures. Most often these are psychedelic substances. In may cases, use of these substances are not yet legal for therapeutic purposes, so I cannot advice you on this directly. However, if you are interested in researching these alternatives for yourself, I would suggest the book called The Psychedelic Explorers Guide by James Fadiman, Ph.D. It has entire chapters on therapeutic uses of these substances and the research behind them.

I’m excited to be sharing an interview with Quinn from Magnolia Mental Health for next week’s podcast! 

Thanks for listening!

Interested in having Duff answer a question on the podcast? Email Duff at robert@duffthepsych.com and maybe you’ll hear it on a future episode!

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