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Suffering With Treatment-Resistant Depression

Question:

I should not be writing to you. I am sure you have millions sending you the same sort of message. I have suffered depression on occasions since I was 31 years of age, although, when well, I am a most positive, encouraging and caring person –

I am now 63. I thought I had cracked it when put on a prescription of Venlofaxine and I was well for many years. However, I cannot even pinpoint why, I went into depression again last January. They told me to increase the medication which I did but to no advantage. Sometimes I don’t even think I am depressed, instead I feel it is my own attitude and that I should be getting on with it and making the most of life, instead of feeling as if I wish I was dead. This time I have even lost my faith in God. I have recently had a series of ECT treatments and have now been put on Quetiapine FUM and Mirtazapine. I still feel depressed? If someone could tell me a sure, quick and easy way of getting out of this life I would take it.

It is not as if I don’t try – I have a job 2 days per week which, although proving difficult at the moment, I have stuck to. I tried going on a horticulture course but realize that it is too technical for me right now and am seriously thinking of telling the tutor I just can’t do it. I try to keep busy at home even though I find it a struggle but I just don’t want to go on.

I have been married for 41 years and I am driving my husband mad. We have a lovely son aged 32 who lives in London, England and he is bringing his partner to New Zealand at Christmas for a holiday. How can I get better for them?

Is there any way in which you can help me?

This Disclaimer applies to the Answer Below
  • Dr. Dombeck responds to questions about psychotherapy and mental health problems, from the perspective of his training in clinical psychology.
  • Dr. Dombeck intends his responses to provide general educational information to the readership of this website; answers should not be understood to be specific advice intended for any particular individual(s).
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  • Always consult with your psychotherapist, physician, or psychiatrist first before changing any aspect of your treatment regimen. Do not stop your medication or change the dose of your medication without first consulting with your physician.
Answer:

Your letter is especially earnest, and you have my strong sympathy. For you, depression is a devastating illness; one that really tears the heart of your life so much so that you contemplate suicide. While you are not bed ridden or hallucinating that you are rotting in place (and depression can get that bad); even though you are still managing to get out and engage in the world a few days a week (which is in most cases a good for someone in your situation to do if they can manage it), you still feel hollow and empty and worthless. You wish you were dead. You’ve worked with your psychiatrist(s) and followed their instructions but presently, it doesn’t seem to be enough.

I restate your situation above to suggest that you have been working diligently to try to beat this illness. You are not a “slacker” (e.g., someone who should feel ashamed of themselves for not trying hard enough) although your letter suggests you still feel like you should be ashamed of yourself. That voice of shame is irrational, I want to tell you. It is part of the depressive illness you find yourself with. Do your best to not take it too seriously.

I cannot take away your suffering, of course. What I can do is to lay out some of the variety of ways that doctors and therapists work with people who are depressed to help them get better.

From the sound of it, you have always gone the psychiatry route with regard to your depression treatment. If you are at the ECT stage, you have experienced most of their treatments at this point. Medicating depression can be a tricky thing. It can be the case that individual patients require a cocktail or mixture of different medications before symptom relief occurs. Or sometimes, no medications seem to work. ECT can be remarkably effective for treatment-resistant forms of depression, but it is also tricky business and may need to be repeated before it provides relief. In some cases, relief may not come from that either.

There are another few medical options for depression treatment you might want to ask your doctors about. These include Vagus Nerve Stimulation (VNS), Transcranial Magnetic Stimulation (TMS), and Deep Brain Stimulation (DBS). All of these procedures involve stimulation of areas of the brain (as does ECT), but each proceeds in a different manner. TMS is a non-invasive procedure that involves the passage of a strong magnetic current through the brain. VNS involves the surgical implantation of a pacemaker device into the outer chest, placed to to stimulate the Vagus Nerve. DBS, the most experimental of these procedures, involves the surgical implantation of a pacemaker lead directly into a particular area of the brain called the subgenual cingulate. None of these procedures is a magic cure, and some of them (e.g., DBS) are so experimental as to be not yet available for all intents and purposes, but they are things you might explore with your doctors.

While medical doctors offer a vital service with regard to treatment of depression, they are not at all the only game in town. There is also the world of psychotherapy for depression which can be explored. You do not mention any experience with this world, which is a true shame as some forms of psychotherapy have been specifically formulated and validated (through extensive scientific research) as effective treatments for depression. There are several formats which are known to work, but the most commonly available one, and also the one with the most evidence showing its effectiveness is known variously as Cognitive Therapy (CT) for Depression or Cognitive Behavioral Therapy (CBT) for Depression. Cognitive psychotherapies are entirely non-invasive and without side effects as they involve nothing more than talking with a therapist. In CBT or CT, however, the therapist is not there to analyze you, but rather to teach you coping skills you can use to get a handle on your thoughts. In the CBT way of looking at things, your thoughts flow from your beliefs, and cause your moods to occur. If you can learn to systematically examine your thoughts and hold them up to the light of day so that errors in your thinking can be corrected, you will begin to alter your beliefs and your moods. If you have not yet explored CBT or CT for your depression, you really should look into it, as it is likely to help.

A quick Google search on “CBT New Zealand” pops up the following links you might explore:

http://www.rational.org.nz/public/referrals.htm
http://www.aliceboyes.com/cbt/
http://www.cbtpsychology.co.nz/cbt/

There are other avenues through which you can treat depression too. Exercise is one, but not just any exercise. Regular and fairly vigorous exercise can help raise one’s mood. Of course, it is a good idea to consult with your physician internist before starting on a program of exercise to make sure you are physically healthy enough to do so.

I encourage you to read over our Depression article which provides a review of the major treatment avenues for depression. I also urge you to remain hopeful even though it is clear that this is difficult for you to do at this point. While you have been working very diligently at treating your depression, it seems that you have only been looking at the medical treatments. There is another whole world or two of alternative and complementary treatment options which can be explored. There is reason to be hopeful.

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