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What Treatments Are Available After You've Tried The Medicines Of Last Resort?

Question:

I have been treated for major depressive disorder for over a year now. Currently I am taking 300mg daily of Effexor XR along with Ritalin to counteract the excessive sleepiness I’ve been getting with the antidepressant. I know that Effexor is considered the drug of last resort for most depressions, and now I am worried because I feel like I have lapsed into a depressive cycle–thoughts of suicide, uncontrollable crying, which led to me getting fired from my job because I wasn’t being productive, my phone and electricity being turned off in my apartment, no money to wash clothes, not caring what or when I eat, and just laying in the dark at home crying because I don’t see any signs of improvement. I can’t afford my psychiatrist anymore, and I was denied free medicine 3 months ago because I earned $125 too much in a year .. although now things have changed (but the drug company refuses to revisit the application until 3 more months have passed). I am past the end of the rope. I feel like the rope has been jerked out of my hands and I have the choice to try to grab it while everyone else looks on and laughs or just resign myself to ending my life and being a burden on myself and others. Is it better for me to end my life with some shred of dignity or continue this downward spiral until something else kills me instead?

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Answer:

Not being a psychiatrist or otherwise empowered to prescribed psychiatric medications, and not knowing anything about your case, I cannot say whether Effexor XR is truly the "medication of last resort" for you. I can tell you that there are still multiple treatment avenues to try even after medications have been exhausted. I can also tell you that I know of patients who have not responded terribly well to particular antidepressants, but who have had better (not perfect but better) success on others, or on various combinations of medications. I don’t know if you’ve been down the road of multiple different medications or not. If you have, it may be time to "graduate" to alternative treatments, and if you have not, it is surely time to alert your psychiatrist that what he or she has you on is not working, and not adequate.

There are several broad treatment categories for major depression, these being medication, psychotherapy, stimulation-based therapies, physical exercise and other behavioral interventions.

I don’t know if you’ve had any experience with cognitive behavioral therapy (CBT) for depression, but it is currently the gold standard empirically supported psychotherapy treatment for major depression. Studies show that CBT works about as well as medication treatments (when they work which they aren’t right now in your case), and that CBT tend to help people remain symptom free for longer periods of time post treatment. Cognitive therapy helps to teach you how to effectively talk back to all those thoughts in your head that are helping you to think that life is not worth living and that things are hopeless. It is a method for discriminating what thoughts and beliefs in your head make sense and which do not, and for how to correct those that do not make sense. For example, from the sound of your letter, you’ve got several thoughts happening in your head these days that could use some counter-balancing. One is that people around you are laughing at you while you grasp at the "rope" (it is actually unlikely that anyone is laughing at your or enjoying your misery), and another is that suicide is a reasonable solution to your problem (it isn’t). When you learn this method and get reasonably good at implementing it, you gain some power over your depressing thoughts. Since thoughts drive your emotional responses and are responsible for a portion of your depression, if you can get your thoughts under control, you will get your emotions under control to a great degree.

Psychotherapies such as cognitive behavioral therapy are appropriate for mild and moderate cases of depression. They would be good for very severe cases too, but when cases of depression are very severe, you tend to have problems such as you are describing where you literally can’t get yourself out of bed, much less practice therapy homework. So therapy is less useful in that case, as you don’t have the energy or motivation to engage it. If you don’t think therapy is worthwhile presently, keep it in mind for a later time when you might be feeling better but still depressed.

In cases of severe major depression which do not respond adequately to medication treatments, the true treatments of last resort are the stimulation based therapies, which presently include electro-convulsive "shock" therapy, and two newer stimulation therapies, including vagus nerve stimulation and transcranial magnetic stimulation. A fourth stimulation based therapy has been reported, involving deep brain tissue stimulation but it is still truly experimental in nature and involves brain surgery which of course is very risky and expensive.

All the stimulation based therapies involve stimulation of nerve tissues in the brain (or nerves in the body that connect to the brain). Vagus nerve stimulation therapy involves the implantation of thin electric wires connecting to the vagus nerve, which is then stimulated regularly with a mild current generated by a pacemaker-like device. In transcranial magnetic stimulation, there are no wires to implant. Instead, the stimulation occurs via an MRI-like device in a doctor’s office during periodic doctor visits. The most widely available stimulation therapy is ECT (electro-convulsive therapy) which involves the passage of a carefully regulated electric current through the brain to induce a seizure. Multiple repetitions of this process have a restorative effect on the brain of very depressed patients. There is some memory loss, mostly of recently remembered information, which is not a good thing, but otherwise the procedure is safe (if still unpleasant to contemplate) and often results in the seemingly miraculous turning around of otherwise treatment resistant depression.

If you can manage it, participating in vigorous physical exercise on a regular basis is known to have an antidepressant effect (as well as a positive effect on your general physical health). Mild exercise isn’t as useful, unfortunately. Exercise is also nice because it gets you out of the house and forces you into the moment and away from your depressive thoughts for a little while.

Your question is really two part, the first being what can be done besides medication for my treatment resistant depression, and the second part being, how do I pay for all this? I’ve given you some options to think about and pursue with regard to the first question, but unfortunately, figuring out the second question is difficult in modern America. Treatment is expensive, and resources are scarce, particularly if you don’t have insurance or a steady paycheck to pay for things. The hopelessness symptoms of depression compound the situation, making it even more difficult for you to advocate for yourself. Despite the real difficulties, your best bet is to persevere with treatment seeking. There are resources available for severe cases in most communities and if you keep after finding them you will have the best chance of gaining access to them. Your local community mental health center or public health center is a good place to find care when you don’t have insurance. If you are disabled because of your illness, which it sounds like you may be, you may qualify for treatment assistance there. The free medication angle is also a good one to continue to pursue. These programs are bureaucratic in nature. If they insist that you wait three months, that is not good, but three months will pass quickly enough and then you can revisit it. There are also several programs described here that help people in your situation hook up with reduced cost or free medication programs, and these might be worth pursuing too.

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