What we’ve said about Treatment-resistant depression

“If you're treating major depression and you're on your third medication in a row with no remission, reconsider your diagnosis”

“I have a, you know, really high threshold. If someone is not doing well on antidepressants to say that they have treatment resistant depression. I would much rather reformulate the patient. I would much rather make sure we're doing the work on affect or personality”

“I've seen patients with 10 or more medication trials, and the reason why the person's kind of going through this laundry of things that are not going to work is a lack of a psychological formulation”

“It is overdiagnosed and underdiagnosed. What we see is patients with a lot of personality pathology, with borderline personality disorder, oftentimes it's overdiagnosed in that context. In those patients in treatment resistant depression, I see it severely underdiagnosed in”

“when you persist with SSRI in someone with bipolarity, that's where it becomes more harmful and dangerous. And there are other treatment options”

“you've asked them, what would you do if you felt better? What if this medication worked and everything changed and you felt differently? What would be different about your life? What would you do differently? And if someone can't answer that very well, I don't see the utility in futile prescribing”

“I almost get a full narrative life history just by like... filling in all those details as to why they switched medications and what was going on during that medication switch”

“as a rule of thumb, say that it's at minimum three quarters of the maximum dose under the FDA approval. If you're not really there, it's not quite an adequate trial. Now, there's reasons to start switching before you get to an adequate dose, obviously, and that's side effects, right”

“A lot of patients are scared to push the dose for a variety of different reasons. You want to find out why and talk about it. You know, there can be good reasons to be afraid. And with a little education, they might feel more comfortable”

“But then if something's not working and it's an adequate dose, you either switch or you augment. Now, I like to augment, but really, the research does not show superiority of one approach or another. You can switch or you can augment”

“my instinct is to switch first just to reduce the number of medications. That said, there are cases where you see a little bit of an effect, but... you have side effects or something that makes you not want to push the dose higher, then I would augment. But I switch is my first instinct”

“The best evidence goes to ECT, TMS, TMS. antipsychotics, particularly aripiprazole has the best evidence and the biggest effect size, lithium, thyroid supplement, and the ketamines, esketamine and ketamine. So those would be our top line interventions”

“at the bottom of that evidence ladder sits bupropion and mirtazapine and basically buspirone, another antidepressant augmenting. So taking two antidepressants rarely ever works better than taking one, which is what we most often do”

“Consider them if you have true treatment-resistant depression, not just we're calling something that's trauma and personality depression. Please consider your TCAs and your MAOIs if you know what you're doing”

“depression is a form of thyroid resistance. And just like we give people with because they're resistant to it, we pump up the thyroid in these patients with depression. They then get more thyroid entering into their cells, particularly in the brain. That's why we tend to prefer T3 triiodothyronine cytomel, because it's more brain active”

“It is a short-term treatment that helps you lift out the depression and then you have to do hardcore lifestyle changes and psychotherapy on top of that”

“They are the folate treatments, folate vitamins, omega-3 fatty acids, probiotics, light therapy, vitamin D, and possibly some hormonal therapies, which I don't recommend psychiatrists do”

“we're not going to find a single treatment like a new medication that's going to pull them out of all these problems. But if we take a broader look at their relationships, their lifestyle, at these kinds of deficits, we might find ways to improve their mood a bit and help them function better in the world”

“the likelihood of each medication trial treating someone's symptoms to remission goes down exponentially with each trial. And depending on where you look, those numbers could be anywhere with first medication trial having a chance on average around 30%, second trial around 20”

“Usually this conversation, we should start having it the moment we start medication trial number two, right”

“Oftentimes when somebody is getting referred to me for ECT, the average number of medication trials is greater than 12. By the time they show up, they're feeling hopeless. They're feeling like this is the last stop on their journey”

“Maybe I can bypass the receptor set and I can just directly stimulate that circuit using cool principles with like electromagnets and inducing currents”