What to do if depression cannot be treated? | Health and wellness

Composer Hector Berlioz described in his Memories “the terrible feeling of loneliness in an empty universe.” In this state, the musician stopped composing, he remained inactive and motionless, since he had no other ability “except to suffer.” Andrew Solomon says that acute depression is both destruction (the instinctive functions of life disappear) and birth (the birth of a demon). Almost all accounts speak of being “on the edge”, which could mean floating around madness or destruction. For those who have not experienced this, it is difficult to imagine. It is bad when this diabolical situation persists over time and continues despite treatment. What to do then?

The first thing to do is make sure that it is truly treatment-resistant depression. The diagnosis must be appropriate; we can never treat blindly. For example, it is necessary to rule out anemia, hypothyroidism, or any other hormonal disorder that might justify the symptoms. Therefore, every patient being treated for depression and anxiety should undergo at least a blood test and a physical examination to rule out these factors. We also need to ask ourselves: is the patient taking any medications for another pathology that could cause depression? Is the patient using any toxic substance that is contributing or aggravating the condition?

Within the framework of mental pathology, depression must be differentiated from bipolar disorder, in which antidepressants are not only ineffective, but can also worsen the condition or differentiate it from an anxiety disorder or personality disorder. We will also need to ensure that treatment attempts are sufficiently long (six weeks with antidepressants) and adherence to treatment is good (30 to 50% of patients do not tolerate treatment well). This will give us a clue to ask the patient how he has responded to treatment in the past.

In the most common definition (failure to respond to two attempts at treatment at adequate times and doses), treatment-resistant depression (TRD) affects 30% of patients. This figure comes from clinical studies that do not include complex patients and where all confounding variables are controlled. In real life, this percentage reaches at least half of patients, and several factors appear to be associated with this resistance: older age, greater severity of symptoms, coexistence of other mental disorders, cognitive dysfunction (eg, concentration or memory), chronic pain, or history injuries. According to the algorithms, the next step is to use various pharmacological tactics that have proven to be effective: combining two antidepressants with different mechanisms of action, replacing one with another from a different family, or enhancing the antidepressant with another substance.

However, this is not exclusively a pharmacological problem. There are many reasons to include psychotherapy in an integrative approach to depression. Firstly, because this is the therapeutic method that patients usually prefer; secondly, because it provides opportunities for emotional learning and managing personal relationships, and encourages resilience and the search for meaning. Third, because meta-analyses show that adding psychotherapy to pharmacological treatment has a modest (but not small) effect.

We can try a bunch of antidepressants, but it won’t work. Likewise, we may needlessly apply multiple psychotherapy approaches to a patient with severe melancholic depression who requires a pharmacological approach.”

The most studied treatments are cognitive-behavioural, interpersonal and attentiveness, although it seems that effectiveness depends less on a specific methodology than on factors common to different schools. International guidelines systematically recommend combined pharmacological and psychotherapeutic treatment. Because when did psychiatry leave psychotherapy aside? The great fathers of psychotherapy, such as Sigmund Freud, Carl Jung, Aaron Beck, Otto Kernberg, Alfred Adler, Viktor Frankl, Eric Berne and Joseph Wolpe, were psychiatrists. And now we have the opportunity to work side by side with clinical psychologists to jointly implement this critical therapeutic tool.

However, the concept of treatment resistance is sometimes too focused on treatment and little dependent on the patient context. There are depressions that are largely due to the devastating experiences of childhood trauma, oppressive family relationships that perpetuate suffering, or an unbearable job. We can try a bunch of antidepressants, but it won’t work. Likewise, we may needlessly apply multiple psychotherapy approaches to a patient with severe melancholic depression who requires a pharmacological approach. It’s important to broaden your focus.

Finally, there are third or fourth line options that can offer greater hope to the patient and their families. Electroconvulsive therapy, despite its terrible reputation, has been shown to be highly effective for treatment-resistant depression. It is carried out under anesthesia, in careful and controlled conditions, so we will have to abandon outdated sequences Someone flies over Cuco’s nest. Transcranial magnetic stimulation is generally better accepted by patients; It has promising evidence, but it is not widely available in our country. Recently, drugs such as ketamine or esketamine (marketed in Spain) have emerged with new mechanisms of action and rapid and apparently sustained effectiveness. These are expensive drugs that should be used judiciously and responsibly in patients with clear indications. Another psychedelic drug, psilocybin, has just gone on sale in Australia, raising high expectations.

In this sense, the emergence of new tools from the pharmaceutical industry is great news. Perhaps some naive people still wonder: are pharmaceutical laboratories non-governmental organizations? Absolutely not. Like Ikea or Zara, these are companies that want to make money. But if they are well regulated and ethically controlled, they are important agents in our healthcare system. In my opinion, uncritically buying all of their sales messages is as wrong as demonizing the industry as a whole, in a story that falls somewhere between conspiratorial and anti-capitalist. The pragmatic and sensible solution is to reconcile your legitimate interests with the interests of society, which is in dire need of scientific advances, both in the field of vaccines and medicines.

To the patient we care for, we will tell him that we will not sit still, that there are many options and that we will do what we can. From different points of view, with the help of different professionals, with one goal: to see with the help of the famous quote by Albert Camus that in the middle of winter there is an invincible summer, and not to lose hope.

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