My space is dark; my darkness is all over. What’s next? What’s now? Why all this? Did I deserve this somehow? Why doesn’t anything or anyone help me? I don’t want to feel like this anymore. An ashen haze envelops me all day, every day with lengthy periods of blackness interspersed so much so that I even welcome gray anymore. I get so frightened that it will never even return to gray-then what? I’m out of control in my head and in my heart; my emotions are so overwhelming and my thoughts so confused that it’s a free fall in an abyss with no limits-just pain and fear; too much indecision, too much distraction without purpose; endless streams of helpless, hopeless banter in an echo-laden head.

I’ve read and been told to “not go gently into that goodnight.” I have fought this-hard, but it hasn’t mattered. There is nothing gentle about any of this. It’s unrelenting pain with no compassion and no identity–it’s invisible. There is no fairness or reason-it just stops and engulfs me-why?! What more can I do? What more can be done? What is this plague?

Depression, especially treatment resistant depression is an insidiously pernicious illness. It can be subtle at first but then it demonstrates that it’s like a parasite-a parasite that steals everything and wants to kill the host.

Depression is a treatable disorder. Most of the time, standardized modalities are very effective in the amelioration or even the alleviation of the disorder. Sometimes however, not as readily–this form is called Treatment Resistant or Refractory Depression [TRD]. There are very minor differences in the definition of TRD, but it is generally defined as: an inadequate response to one, [or at least two or more], antidepressant trials of adequate doses and duration. Unfortunately, this is a relatively common occurrence (See Diagnosis and Definition of Treatment Resistant Depression, M. Fava; March 8, 2017).

In clinical practice this is seen up to 50 to 60% of the time. Subsequently, it is recommended that a diagnostic reassessment of these patients be performed in an effort to achieve better outcomes. There are many potential contributing and confusing factors that may be involved and not initially obvious. Examples of medical conditions include Parkinson’s disease, thyroid disease, stroke, COPD, cardiac issues, unrevealed substance abuse, and significant personality disorders can be culprits. Other potential contributors include comorbid psychiatric disorders like anxiety, psychosis, early dementia, bipolar depression diagnosed as unipolar, trauma or abuse not determined initially, chronic pain, other medication interactions and/or patient noncompliance. Ascertaining all of these potential variables is both essential and challenging for the clinician as well as the patient. Collaborative historians are very valuable to assist in shedding light on the problem, i.e. family, coworkers, teachers, etc. All of these individuals or groups would, of course, require the patient’s permission because of privacy laws. Reliable psychosomatic rating scales can be useful to detect, and in some cases, begin to quantify the severity of the issue. There are varying degrees of resistance. Some readily responsive to minor adjustments in treatment and others are much more tenacious.

Treatment options can include many different modalities. Usually the first level of alternative care is achieved by increasing the dose, changing or adding (augmentation) antidepressants or other non-antidepressant medications such as Lithium, several atypical antipsychotics, stimulants or thyroid hormone for example. Again, adequate doses and duration are required. Patients must first be able to tolerate the medications or combinations due to the potential side effects or adverse reactions that always pose a potential risk.

The risks and benefits for all medications recommended should be discussed with the patients before they are tried. The discussion should also include any alternative therapies, and/or the possible outcomes if a patient choses to forgo the recommended treatment. The patient must understand and then agree, or not, to the treatment plan being suggested before it is begun. This is the process of informed consent.

In addition to other modalities of treatment, Electroconvulsive Therapy (ECT) can be safely utilized for severe refractory depression or in patients with serious depression who cannot tolerate standard antidepressant medications.

Vagus Nerve Stimulation, Transcranial Magnetic Stimulation, and other newly emerging methods of direct and select brain stimulation have been shown to produce efficacious results as well. The arsenal of successful treatment also includes Ketamine IV infusion for resistant depression.

Psychotherapies of varying types have been assessed as effective and often necessary methods to assist with medication therapies in the fight against refractory depression; i.e. Cognitive Behavioral Therapy, Interactive-Interpersonal, Dialectical Behavioral and yes, even Analytical in some cases, have all been proven to be potentially effective. Treatment to remission, meaning no remaining symptoms, needs to be the goal or recurrence is likely.

Outcomes for patients with TRD can be very varied. Relapse rates tend to be greater and swifter in patients with TRD. It is essential that these patients be assessed and treated only by well-trained and experienced behavioral health specialists. This form of depression is certainly treatable. Hope and trust must be inherent in the treatment plan.


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