Great. Appreciate your succinct and systematic approach. A lot of folks on TH-cam producing vids where the aim seems to be hearing themselves talk. There's real value here, well-delivered. Thanks!
Thank you - I haven't heard TRD described so succinctly. As a 51 year old woman, with an ACES score of 10 and many many many rounds of meds, therapy, ECT, TMS, ketamine, etc. - I know that the psych field still has a long way to go. Ketamine has worked for me for the last 4 years. Most of the time I can come out of a depression for about 1-2 weeks, which is incredibly useful in feeling better - but, I'm always riding the cycle, it is extremely expensive, and seems to be working less and less even while increasing the dose.
I like Ketamine it has a place in the treatment of depression and acute suicidaility. You are right by saying we are still in the process of figuring out how often someone should have ketamine treatments and should they be on maintenance or just continue with standard medications. There are many questions to answer but I believe with good people and a lot of excited young psychiatrists we can make some advancements in the field. If you haven’t subscribed already, please do, and spread the word about what we are doing here.
Best option: MAOIs. Nardil and Parnate. Very very effective medications. The contraindications and interactions are much less than previously thought, too.
I'm impressed hearing a fairly young (or very gracefully ageing) psychiatrist talk about using MAOIs. They are underused in TRD and established medication-responsive depression to a nearly criminal degree. I'm a huge fan of Dr. Gillman's protocol. Sertraline up to the max dose, add nortriptyline next if there's inadequate response, then stop sertraline and start tranylcypromine 7 days later if there's inadequate response. It is strange to me though that people are so afraid of SE's from tranylcypromine. I had some orthostatic issues when I finally got up to an effective dose, but it was easily managed with some salt tablets and went away after a few days. The only other somewhat annoying SE was pupil dilation, especially at night, which made driving a little rough for a couple weeks. I eat whatever I want, even things traditionally labeled with a skull and crossbones for MAOI patients and have never had any BP issues. Also have pretty bad ADHD, had to taper up on vyvanse/adderall again after starting TCP, and ended up on a much lower dose than before but haven't had any issues there either.
I love how you say just stop those medication and start a new one. I recommend you take the easy ones, ssri and snri ‘s for a month and just stop and try something new.
People’s responses to medications and need to taper vary widely. Some people do not require a taper at all, and others require a prolonged taper. It’s hard to describe all the nuance points in a short video, so to clarify we need to complete adequate trials of each medication prior to switching or augmenting. It’s best to taper medication and not stop it abruptly even it’s a medication with a long half-life like fluoxetine. You are right it’s not a simple process and requires careful planning, should have made that more clear in the video. Hope this helps
I didn't know there were so many options. I am at stage 2. I am on effexor and just had the dose increased. Sometimes I start thinking "what if this medication eventually stops working? What happens when I run out of medications to switch to?" This provides me with hope - there are plenty of steps ahead of me if I need them. I hope I never need them but at least I know it's there
There is always hope, and people do get better. We have to know the limitations of medication and the hallmark of a good doctor IMO is one who knows the limits to what these treatments can do. Also remember these medications are symptoms management and not disease modifying. Knowing when to continue medication and when to stop or decrease medication is also important for doctors. If you haven’t subscribed already, please do, and spread the word about what we are doing here.
I've been at this half my life. Done all the different classes of medications plus augmentations, TMS, ECT, Ketamine, CBT, DBT, IOP, PHP, inpatient, outpatient therapy for years. No one knows what to do with me. Any suggestions. I'm desperate as every psychiatrist I go to just tells me they've done all they can and get another opinion.
As I said in a previous comment to another subscriber, we have to change our mindset. Many people get caught up chasing remission and a cure but depression is a chronic disorder and you can find yourself feeling worse just chasing. I think it's best to start figuring out with your doctor and therapist what can I do to cope with these symptoms and how can I still live a meaningful life. I always think about life worth living goals and finding ways to contribute to the world in a way that makes you feel like there is more to life than living with depression. I hope this helps, and this is by no means saying medication and therapy are not helpful or that all hope is lost it's just about taking a new approach
There is also vortioxetine which goes by the brand name Trintellix. It's in a class of antidepressants called the SMS (Serotonin Modulator and Stimulator) class which also includes vilazodone which goes by the brand name Viibryd.
You could try those medications, the data I've seen on them is they are not much better than the other less expensive options. On a case by case basis one person may respond better to these medications than an SSRI or SNRI for example but it's hard to predict who that person will be. I do like the possible cognitive benefits associated with Vortioxetine but I would like to see it compared head to head with duloxetine as this is the antidepressant with the most evidence. We need to cover these medications on the channel as several have asked about them, look out for videos soon. If you haven't subscribed to the channel please do, and spread the word about the community we are building here.
I’m a veteran who has TRD and PTSD for a long long time. The VA used me as a lab rat and I took every triptaline in the book. Took all kinds of stuff that didn’t work. They would NOT give me a benzo. I used my Navy insurance for private care and 4 years later I’m on a steady treatment of counseling and Diazepam, 5mg 3x daily and my crippling back spasms and severe anxiety and depression has become TOLERABLE. It’s sad that most Drs assume Benzodiazepines equal addiction-period. Physically and mentally depending on something isn’t addiction. Most of these meds in the physiatrist’s first line of defense are meds that are nothing more than a lobotomy.
Wow there's a lot to unpack in this statement. Let's start with the lobotomy thing, this is not true at all and makes no sense from a scientific or physiological standpoint. I've never used anyone as a "lab rat" and I don't think i've ever met a psychiatrist who has, I've personally worked at the VA and treated patients there so I can speak directly to that point. No self respecting psychiatrist says "ALL" benzodiazepines are bad and no one should ever use them. They are a tool and can be useful in the right circumstances. Physically and mentally depending on something is literally the definition of addiction. As for PTSD, the scientific data tells us that benzodiazepines impairs patients ability to participate in trauma focused psychotherapy and prevents memory reconsolidating. The therapy is really what helps treat PTSD and using benzodiazepines can prevent that therapy from being effective. Either way, I'm glad you found the treatment that works for you and I wish you the best on your mental health journey
@@ShrinksInSneakers so when trying to treat CPTSD, it is recommended to not be on a benzodiazepine? I’ve been taking one for over 10 years now. I also have recently not had much luck finding an AD to work after Effexor stopped working around Christmas time last year. Is it true that if you’ve responded before you are likely to respond again to another AD? What about the use of a benzodiazepine during treatment of ECT or Ketamine?
@@danielspiess8641 There is evidence that the use of benzodiazepines in PTSD can interfere with psychotherapy because the patient needs to experience the physical symptoms associated with the trauma to reconsolidate the memories effectively. I'm not a big fan of using benzodiazepines in someone who is undergoing psychotherapy for PTSD. Response to antidepressants is difficult to predict what I can say is as the number of episodes of depression increase the likelihood of a response to medication decreases. Things that indicate a person may respond to medications are history of prior response, and family history of someone taking the medication and responding well, such as a first degree relieve like mother or father. For ECT no benzodiazepines because they will increase seizure threshold which is the opposite of the goal in ECT. For ketamine I don't think anyone has studied this extensively but I would say it's better to not be on them and here is an article that supports this point www.frontiersin.org/articles/10.3389/fpsyt.2020.00844/full
I read plenty of references back to the Star*D trials, which were done back in 2006. Wouldn't you think it might be time for an updated version? Or has there really not been that much advancement in psychopharmacology?
STAR-D has provided a lot of valuable data. The most recent advances in depression treatment have been related to breakthrough treatments like ketamine and psilocybin. There is need for new mechanism and I think we are on the way but the rediscovery of some of the older medications like MAOIs can also be helpful as they generally have better efficacy over modern antidepressants. Hope this helps, appreciate the comment
As far as depression goes, I just had some questions about it. I remember seeing some graph awhile ago showing the different 'phases' someone goes into, to get to TRD. Something Like you get your first major depression diagnosis, get better and have no lingering problems. 2nd major depression it becomes harder to treat, but you still can get better with medicine and therapy. 3rd time it's considered TRD, and becomes very hard to treat, and so on etc etc. Do you believe that this is true? I wish I could remember the name of it, as to show you what I'm talking about. I've just always wondered if that can really happen to a person, going through those stages to developing TRD. Maybe you have some insight into this. ty
In many cases it's defined as two failed adequate trials. I think you are talking about the concept that after three major depressive episodes the likelihood of another episode is very high and warrants continued medication treatment with no defined end point. In many cases first MDEs can be treated for 6-12 months and then consider tapering off medication or at least lowering to the lowest effective dose. Let me know if you remember the study
This will depend on the person. If someone comes to you with treatment resistant depression they have either tried these things and failed or are unwilling to make the necessary lifestyle changes. Exercise is the pill no one likes swallowing and we always discuss the impact of diet and exercise on mental health with every patient. I'm also not of the mindset that lifestyle modification alone will cure severe cases of depression (mild to moderate sure start with lifestyle and avoid medication if possible), they are great things to add to treatment nonetheless
Hello! I’m wondering if you can speak to treatment resistant bipolar 2 depression? I’ve been on a plethora of med cocktails, ECT including bilateral, and currently been going for weekly ketamine infusions for the past year that help a bit but the effects wear off after a few days before sinking again, and as well as weekly therapy. All of this and still suffering and not very functional though I have improved mildly since starting the ketamine last year. ALSO, I may be sensitive but I’d really love for you to reword “the person has failed to respond to medication”… I know I sound like I’m knit-picking and that you don’t mean it this way but it comes across as blaming the patient for not responding to meds like it’s a choice or something, but it’s the disorder not responding not the person.
This is a good topic to talk about, I think we can do something on treatment resistant bipolar. A recent article talked about using thyroid hormone really interesting stuff.
I really like the prospect to rediscovering some of these medicines and doing the necessary research to elicit all the potential benefits and side effects. Psilocybin is coming and will likely be available as an FDA approved medication in the near future. The research at John Hopkins is very good and promising for a number of psychiatric and substance use disorders. I’m not sure about micro dosing, most of the research I’ve seen used 20-30 mg/70 Kg with better results at 30 mg/70kg doses. My one word of caution is that I do not believe these medications are “disease modifying.” What I mean by this is a patient may still be prone to having another depressive episode in the future. Psilocybin may increase the length of time between depressive episodes and require less frequent dosing which is a major improvement over daily oral medication for depression I’m not convinced by the data that using this medication will cure psychiatric and substance use disorders but I’m excited to see what the data will show when it’s widely available. Appreciate the interest and comment about psychedelics and I’m excited about the potential.
@@ShrinksInSneakers what would you suggest to someone who is essentially trapped on ssris but wants to try psilocybin? I desperately want to ween off so I can try it, but have had no luck for years due to withdrawals.
@@zila626 I always taper in my practice and sometimes you need a very slow tapper over several months to effectively come off. In some cases switching to fluoxetine can help due to the long half-life and less potential for withdrawal. If you haven't watched the video I did on Psilocybin you should it's paced with good information and the latest research. If you haven't subscribed please do and help me spread the word
What do you recommend after 22 ECT treatments did nothing, Ketamine did nothing. What about VNS. The only thing I haven’t done is MOAI due to the restrictions.
I think it's more about changing the mindset at that point. When I work with people we start to shift our focus from remission to, how can i live with theses symptoms and still function at a good level. VNS and BDS are major surgical procedures so carefully consider those options with your doctor. These procedures are still not disease modifying so there is still the risk of having another depressive episode. I just covered MAOIs in my latest video it should give you a good idea about the medication and dietary restrictions which are not too bad in my opinion. Hope this helps
My therapist tried 10 types of antidepressants, but still no hope😞 I just wanna know how life feels like without depression, like other people,can they really feel "joy" ? I forget how that feels like
Please talk with your doctor as I cannot offer any medical advice just general information for education. After 5 trials of medication pharmacotherapy is unlikely to result in remission of symptoms, not to say there is not value but there may be some residual symptoms that always linger around. In those cases things like ECT, TMS, and ketamine can be considered and if they are not options then the next step is asking how can I live with some residual depressive symptoms and still be safe and productive? I think it's possible and there is always hope. Hang in there
I tried everything as well. Then tried Ketamine Infusions, expensive and worsened my anxiety. Then I read about Symbyax ( Prozac and Olanzapine) and I felt much better. Didn’t last long, only 3 months then back to depression. Give Symbyax a try if you haven’t.
I've been on at least 20 different medications, SSRI, horrible things like olanzapine (ruined my physical health and worsen my mental health), currently on Venlafaxine which it has been what makes me feel a more tolerable kind of depression. I rather live and die in this gloomy state than consent ect. I would never allow that.
It's a difficult place to be. I think there are still options and talking with your doctor about other potential medications, or procedures is worth it. ECT has it's down sides, mainly the memory disturbances but it also has the best efficacy for the treatment of depression. It's always hard and careful discussion about all options is most important
why do they say the TCA's like Nortryptiline are good for people failing many meds, and Lamictal etc. Seoquel works for me at 75mg for some sedating properties but weight gain and blood pressure are a concern. Thats not asking for advice but.. isnt TCA just a more potent SNRI?
The binding properties will differ depending on the mediation. In some ways TCAs are like SNRIs but they will not have the exact same properties and many SNRIs are less potent norepinephrine reuptake inhibiotrs, for example Effexor does not start working on norepinephrine until 225 mg is reached. I did a whole video looking at which SNRIs have the most effect on norepinephrine. Hope this helps
I am at stage 5 with more than 5-7 failed meds. and cocktails. i have also done, with no success at all TMS. now i'm at Ketemine and ECT, neither of which is covered by insurance???
There is always hope. Medications at this stage are unlikely to result in full remission but they can still help, and maybe we start to change the mindset to how can I live a good life even if I have some symptoms of depression. I hope this helps, if you haven't subscribed to the channel please do and spread the word about what we are doing here.
@Shrinks In Sneakers Thank you Sir for your concern. unfortuantly it you have ever had Treatment Resistant Depression/anhedonia maybe same thing, and tardive dyskinea which eliminates antisycotic meds. what you say is not possible, you cannot live with flatline emotions and feelings. ETC or deep brain messsage is all that left except suicide
I think I talked about it in the video, but after 5 medication trials there seems to be very little evidence that another medication is going to solve the problem. At that point the mindset changes from finding total relief of symptoms to how can I live with these symptoms and still be functioning well and living my life. It's not giving up just changing the thinking around treatment. There is so much more to this, possibly it's not a biological issue at all, there are many causes of depression and many ways of approaching treatment. I think the biggest mistake we made with depression was lumping them all into one category of major depression. Hope this helps, if you haven't subscribed to the channel please do and spread the word about what we are doing here.
@@user-xb3vl2gs7g I don't know your case so I can't comment specifically but in my experience sometimes changing the goal from remission to how can I deal with this actually helps people get better. There is a lot of pressure if the goal is complete remission. It doesn't mean you shouldn't get treatment and all is lost
I've been on about 3 dozen different medications over the last 20 years to try to combat my trd. Ketamine has been an absolute God send for me. What are your thoughts on Interventional Psychiatry? Maybe you could make a video on it! I feel like it's a psychiatry subspecialty that not many are familiar with
Would you consider a trial of venlafaxine 75-225mg over 11 weeks adequate if the symptoms don't improve in the slightest and instead keep getting worse (I know the max. dose is 375mg)? When I started 150mg (1month on this dose) my depressive symptoms gradually became worse and at 225mg (over 3 weeks) it became a disaster. I was on 37,5mg for about 3 weeks, 75mg - 4 weeks, 150mg- 4 weeks and 225mg-3 weeks. Prior to that I was on vortioxetine (my first antidepressant trial, chosen because of cognitive issues) 5-20mg over a span of 20 weeks with no improvement whatsoever. Would you consider these 2 failed trials? My emotional numbness, apathy and anhedonia seemed to get worse with increasing the dosage of both medications. Soon I will be visiting a new psychiatrist and was wondering is it even worth trying an SSRI on its own as the 3rd option? Sorry for this long comment, love your videos :)
This sounds like failed trials based on the duration and dose of medication. For mild/moderate chronic depressed mood you have to question if it's a personality trait on temperament in which case it would respond better to psychotherapy possibly CBT. In general we are talking about severe depressive episodes unresponsive to treatment. Many factors will determine which treatment is right for a given person. If speed of recovery and rapid remission is the goal ECT or ketamine may be options. Hope this helps, appreciate the comment
I'm on mitrazapine, venlafexine, olanzapine, clonazepam, etizolam, lithium, Bupropion and propapanol and nothing is working 😭😭😭 suicidal ideation not going 😭😭 My doctor just put me on drugs 😭
Failure of two adequate trials would define treatment resistant depression. What I’m describing here is a longer algorithm for the treatment of TRD. I defined it at the beginning of the video as failure of at least two trials, but it’s not uncommon for patients to fail more than two trials and after about 7 trials based on the research medication is unlikely to work. At that point it’s more about strategies to cope with the depression understanding that complete remission is unlikely. Hope this helps
Meanwhile I’m still depressed …because all these 5 thing’s haven’t worked .iv spent what little money I had 🤨 now I’m broke and depressed … in Western Australia one cycle of ECT will cost you. At least $1500 dollars 🤯 .
This is not medical advice, and it's only for educational purposes. Please talk with your doctor before making any changes. I think there are a few things to say here, once someone has had 5 adequate trials of medication it's clear at that point that medication is unlikely to fully solve the problem this has been validated by one study. At that point either ECT or ketamine are the best options. I understand the struggle with getting things covered and essential treatments like ECT. I do not think health care anywhere is perfect and there are certainly disparities based on finacial circumstances. I think the other important thing to change is the focus from remission to "how can I live with these symptoms and still have a productive life?" There are ways to still have a good meaningful life even with depression. I think it's important to remain hopeful that things can get better. This does not mean that medicine will not be helpful it's just a different way of looking at things. I hope thins helps, if you haven't subscribed to the channel please do, and spread the word about what we are doing. I'm happy to answer an additional questions
Why don’t psychiatrists recommend adding magnesium supplements to their patients when trying to treat treatment resistant depression? Is it not true that magnesium helps block nmda receptor just as the same way ketamine does? And isn’t there any truth that depression could possibly be related to inflamation? since magnesium taken at a correct dosage could work as a anti inflammatory as well and help the inflammation as well?🤷 I do know when I take epsom salt baths they leave me more alert and less depressed but eventually wear off. But I never had any results taking pill form because I don’t think we fully ingest the magnesium Like we do if we were to from a magnesium lotion or bath salts?
I would say most psychiatrists would be fine with someone adding a magnesium supplement. The problem with supplements is they are largely unregulated and purity and potency of products varies greatly. The other answer is often people have tried complementary and alternative medicines which is usually why they are coming for an intake in the first place. I like the idea of adding diet, exercise, and CAM therapies but they are unlikely to result in remission for patients with true TRD. Hope this helps, if you haven't subscribed to the channel please do and spread the word about what we are doing here
I've covered all those things in other videos. All lifestyle interventions have value and should be added to treatment, I generally incorporate supplements, exercise and diet for everyone. However, lifestyle alone is unlikely to help those with severe depression, what we are talking about in this video is treatment resistant depression, people who have already done all the things you listed and tried a few medications but still have not reached remission. For mild to moderate depression start with CBT and lifestyle interventions first line and only move to medication after these things have been tried. All the research indicates the same trend, as severity increases medications separates more and more from placebo. Hope this helps, If you haven’t subscribed to the channel, please do and spread the word about what we are doing here. We also have daily content on Instagram @Shrinks_In_Sneakers
Dude, if you're mired in depression that's lasted for decades and has ruined or attenuated every relationship you've had with anyone who's ever cared about you, that has caused your enthusiasm for anything other than sleeping to evaporate, and has taken any available energy you manage to force out of your destroyed will simply to get out of bed and fake your way through a workday, exercise isn't an option. You might as well suggest that I take a trip to Saturn. Intense physical exercise is the best antidepressant ever - I agree with you 100%. The trouble is I'm not 17 and I don't have Infantry School Drill Sergeants compelling me to do grass drills in a mud pit for three hours. Getting past that soul crushing monster to go for a 20 minute walk is a prospect even less realistic than becoming a Korean pop star (in my hopelessly gakked brain anyway).
@@wes11bravo just start wherever you are ... Start with 1 min of exercise Start with 1 pushup I get what your saying but if I pulled myself out then anyone can because I was super FUBAR
That’s all good and well if you have the financial resources to spend on Dr’s and medications. And to pay for psychologist . But when you are struggling to pay your existing bills . And you already don’t drink smoke or have a social life ….where am I going to get the money to pay for this help ? 🤯 . Iv been dealing with this T.R.depression for decades ….in the past when it gets to critical mass I’ve , gotten help ….but that has depleted what little funds I had . Now my mortgage gets bigger by the day . And the family pressures are crushing Us . So what’s Your suggestion now ? 🤨 . These airyfairy advertising things are so bloody frustrating . You can find help if you have the money …. Less and less of us have the money day bye day . NOW WHAT ?? In Australia the medical system is linked to the insurance data base …. When I let my life insurance lapse because I couldn’t afford to renew it …. Then tried to get another life insurance policy a few months ago .my premium,s were going to be more expensive because of my mental health records. So now I still can’t afford life insurance. GREAT 🤨🤯 now if something happens to me my family has nothing 🤯 . HOW CAN I FIX THAT ? 💰💰💰💰💰🤨.
See my other response for more detail, but here in the states I can get people ECT without issue even with government insurances. I do understand the struggle associated with getting care covered, noting in medicine is easy and unfortunately there are disparities in all medical services related to socioeconmic factors. I know it's hard but hang in there keep fighting, good things can still happen.
This is why we need "social" care, not just individual. So many of us are depressed because there is something "right" with us- our society is broken and we can't ignore it like some. Putting my plug in here for universal basic income even if it's a long way off
@@zila626 I agree that there is far more to mental health than just medication and psychotherapy. Housing first initiatives, living wages, affordable healthcare all play a role. I will keep advocating for these things on my end, please do the same
Tried 14 different stupid medications and talk therapy, counselors, whatever. Nothing has worked and you want me to trust you to shock my brain? Oh hell no.
Dr. I need your opinion about a patient taking vortioxetine 20mg+effexor225mg+ +Modafinil400mg and recently added Abilify 10mg and made him very good first 2 week but began to sink down and now not that good
I'm not a psychiatrist but I can suggest combining the Effexor with Remeron instead of Vortioxetine. That combination, though risky, garnered the moniker of "California Rocket Fuel" due to its effectiveness. I've improved significantly on that combination but could still use another adjunct medication, like Modafinil, to help with residual cognitive dysfunction and anhedonia.
Great. Appreciate your succinct and systematic approach. A lot of folks on TH-cam producing vids where the aim seems to be hearing themselves talk. There's real value here, well-delivered. Thanks!
Appreciate the comment, the goal is to provide value to people, and offer an alternative approach to traditional psychiatry
Thank you - I haven't heard TRD described so succinctly. As a 51 year old woman, with an ACES score of 10 and many many many rounds of meds, therapy, ECT, TMS, ketamine, etc. - I know that the psych field still has a long way to go. Ketamine has worked for me for the last 4 years. Most of the time I can come out of a depression for about 1-2 weeks, which is incredibly useful in feeling better - but, I'm always riding the cycle, it is extremely expensive, and seems to be working less and less even while increasing the dose.
I like Ketamine it has a place in the treatment of depression and acute suicidaility. You are right by saying we are still in the process of figuring out how often someone should have ketamine treatments and should they be on maintenance or just continue with standard medications. There are many questions to answer but I believe with good people and a lot of excited young psychiatrists we can make some advancements in the field. If you haven’t subscribed already, please do, and spread the word about what we are doing here.
Best option: MAOIs. Nardil and Parnate. Very very effective medications. The contraindications and interactions are much less than previously thought, too.
I'm impressed hearing a fairly young (or very gracefully ageing) psychiatrist talk about using MAOIs. They are underused in TRD and established medication-responsive depression to a nearly criminal degree. I'm a huge fan of Dr. Gillman's protocol. Sertraline up to the max dose, add nortriptyline next if there's inadequate response, then stop sertraline and start tranylcypromine 7 days later if there's inadequate response.
It is strange to me though that people are so afraid of SE's from tranylcypromine. I had some orthostatic issues when I finally got up to an effective dose, but it was easily managed with some salt tablets and went away after a few days. The only other somewhat annoying SE was pupil dilation, especially at night, which made driving a little rough for a couple weeks.
I eat whatever I want, even things traditionally labeled with a skull and crossbones for MAOI patients and have never had any BP issues. Also have pretty bad ADHD, had to taper up on vyvanse/adderall again after starting TCP, and ended up on a much lower dose than before but haven't had any issues there either.
I love me some MAOIs as well, I can't comment on why so many people are afraid to use them but I believe they ay be the most effective antidepressants
I love how you say just stop those medication and start a new one. I recommend you take the easy ones, ssri and snri ‘s for a month and just stop and try something new.
People’s responses to medications and need to taper vary widely. Some people do not require a taper at all, and others require a prolonged taper. It’s hard to describe all the nuance points in a short video, so to clarify we need to complete adequate trials of each medication prior to switching or augmenting. It’s best to taper medication and not stop it abruptly even it’s a medication with a long half-life like fluoxetine. You are right it’s not a simple process and requires careful planning, should have made that more clear in the video. Hope this helps
Very informational. I have TRD & MMD
I didn't know there were so many options. I am at stage 2. I am on effexor and just had the dose increased. Sometimes I start thinking "what if this medication eventually stops working? What happens when I run out of medications to switch to?" This provides me with hope - there are plenty of steps ahead of me if I need them. I hope I never need them but at least I know it's there
There is always hope, and people do get better. We have to know the limitations of medication and the hallmark of a good doctor IMO is one who knows the limits to what these treatments can do. Also remember these medications are symptoms management and not disease modifying. Knowing when to continue medication and when to stop or decrease medication is also important for doctors. If you haven’t subscribed already, please do, and spread the word about what we are doing here.
@@ShrinksInSneakers Thank you!! Yes, I definitely subscribed! I also followed on Instagram 😃 You have the most helpful psych ed content available
@@meagancauble4010 thank you so much, instagram is still a work in progress 😀
I've been at this half my life. Done all the different classes of medications plus augmentations, TMS, ECT, Ketamine, CBT, DBT, IOP, PHP, inpatient, outpatient therapy for years. No one knows what to do with me. Any suggestions. I'm desperate as every psychiatrist I go to just tells me they've done all they can and get another opinion.
As I said in a previous comment to another subscriber, we have to change our mindset. Many people get caught up chasing remission and a cure but depression is a chronic disorder and you can find yourself feeling worse just chasing. I think it's best to start figuring out with your doctor and therapist what can I do to cope with these symptoms and how can I still live a meaningful life. I always think about life worth living goals and finding ways to contribute to the world in a way that makes you feel like there is more to life than living with depression. I hope this helps, and this is by no means saying medication and therapy are not helpful or that all hope is lost it's just about taking a new approach
There is also vortioxetine which goes by the brand name Trintellix. It's in a class of antidepressants called the SMS (Serotonin Modulator and Stimulator) class which also includes vilazodone which goes by the brand name Viibryd.
You could try those medications, the data I've seen on them is they are not much better than the other less expensive options. On a case by case basis one person may respond better to these medications than an SSRI or SNRI for example but it's hard to predict who that person will be. I do like the possible cognitive benefits associated with Vortioxetine but I would like to see it compared head to head with duloxetine as this is the antidepressant with the most evidence. We need to cover these medications on the channel as several have asked about them, look out for videos soon. If you haven't subscribed to the channel please do, and spread the word about the community we are building here.
Ect has saved my life 3 times but I'm struggling to get again it in the UK on NHS ( it's last resort ) expensive for nhs
I’m a veteran who has TRD and PTSD for a long long time. The VA used me as a lab rat and I took every triptaline in the book. Took all kinds of stuff that didn’t work.
They would NOT give me a benzo.
I used my Navy insurance for private care and 4 years later I’m on a steady treatment of counseling and Diazepam, 5mg 3x daily and my crippling back spasms and severe anxiety and depression has become TOLERABLE.
It’s sad that most Drs assume Benzodiazepines equal addiction-period.
Physically and mentally depending on something isn’t addiction.
Most of these meds in the physiatrist’s first line of defense are meds that are nothing more than a lobotomy.
Wow there's a lot to unpack in this statement. Let's start with the lobotomy thing, this is not true at all and makes no sense from a scientific or physiological standpoint. I've never used anyone as a "lab rat" and I don't think i've ever met a psychiatrist who has, I've personally worked at the VA and treated patients there so I can speak directly to that point. No self respecting psychiatrist says "ALL" benzodiazepines are bad and no one should ever use them. They are a tool and can be useful in the right circumstances. Physically and mentally depending on something is literally the definition of addiction. As for PTSD, the scientific data tells us that benzodiazepines impairs patients ability to participate in trauma focused psychotherapy and prevents memory reconsolidating. The therapy is really what helps treat PTSD and using benzodiazepines can prevent that therapy from being effective. Either way, I'm glad you found the treatment that works for you and I wish you the best on your mental health journey
@@ShrinksInSneakers so when trying to treat CPTSD, it is recommended to not be on a benzodiazepine? I’ve been taking one for over 10 years now. I also have recently not had much luck finding an AD to work after Effexor stopped working around Christmas time last year. Is it true that if you’ve responded before you are likely to respond again to another AD? What about the use of a benzodiazepine during treatment of ECT or Ketamine?
@@danielspiess8641 There is evidence that the use of benzodiazepines in PTSD can interfere with psychotherapy because the patient needs to experience the physical symptoms associated with the trauma to reconsolidate the memories effectively. I'm not a big fan of using benzodiazepines in someone who is undergoing psychotherapy for PTSD. Response to antidepressants is difficult to predict what I can say is as the number of episodes of depression increase the likelihood of a response to medication decreases. Things that indicate a person may respond to medications are history of prior response, and family history of someone taking the medication and responding well, such as a first degree relieve like mother or father. For ECT no benzodiazepines because they will increase seizure threshold which is the opposite of the goal in ECT. For ketamine I don't think anyone has studied this extensively but I would say it's better to not be on them and here is an article that supports this point
www.frontiersin.org/articles/10.3389/fpsyt.2020.00844/full
I read plenty of references back to the Star*D trials, which were done back in 2006. Wouldn't you think it might be time for an updated version?
Or has there really not been that much advancement in psychopharmacology?
STAR-D has provided a lot of valuable data. The most recent advances in depression treatment have been related to breakthrough treatments like ketamine and psilocybin. There is need for new mechanism and I think we are on the way but the rediscovery of some of the older medications like MAOIs can also be helpful as they generally have better efficacy over modern antidepressants. Hope this helps, appreciate the comment
As far as depression goes, I just had some questions about it. I remember seeing some graph awhile ago showing the different 'phases' someone goes into, to get to TRD. Something Like you get your first major depression diagnosis, get better and have no lingering problems. 2nd major depression it becomes harder to treat, but you still can get better with medicine and therapy. 3rd time it's considered TRD, and becomes very hard to treat, and so on etc etc.
Do you believe that this is true? I wish I could remember the name of it, as to show you what I'm talking about. I've just always wondered if that can really happen to a person, going through those stages to developing TRD. Maybe you have some insight into this. ty
In many cases it's defined as two failed adequate trials. I think you are talking about the concept that after three major depressive episodes the likelihood of another episode is very high and warrants continued medication treatment with no defined end point. In many cases first MDEs can be treated for 6-12 months and then consider tapering off medication or at least lowering to the lowest effective dose. Let me know if you remember the study
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questions to ask.. what are the behavioral changes the person has made? their exercise and diet? enviornemnt? thinking patterns? 🤔
This will depend on the person. If someone comes to you with treatment resistant depression they have either tried these things and failed or are unwilling to make the necessary lifestyle changes. Exercise is the pill no one likes swallowing and we always discuss the impact of diet and exercise on mental health with every patient. I'm also not of the mindset that lifestyle modification alone will cure severe cases of depression (mild to moderate sure start with lifestyle and avoid medication if possible), they are great things to add to treatment nonetheless
Hello! I’m wondering if you can speak to treatment resistant bipolar 2 depression? I’ve been on a plethora of med cocktails, ECT including bilateral, and currently been going for weekly ketamine infusions for the past year that help a bit but the effects wear off after a few days before sinking again, and as well as weekly therapy. All of this and still suffering and not very functional though I have improved mildly since starting the ketamine last year. ALSO, I may be sensitive but I’d really love for you to reword “the person has failed to respond to medication”… I know I sound like I’m knit-picking and that you don’t mean it this way but it comes across as blaming the patient for not responding to meds like it’s a choice or something, but it’s the disorder not responding not the person.
This is a good topic to talk about, I think we can do something on treatment resistant bipolar. A recent article talked about using thyroid hormone really interesting stuff.
Very interesting, thanks!
What do you think about psychedelics?
I really like the prospect to rediscovering some of these medicines and doing the necessary research to elicit all the potential benefits and side effects. Psilocybin is coming and will likely be available as an FDA approved medication in the near future. The research at John Hopkins is very good and promising for a number of psychiatric and substance use disorders. I’m not sure about micro dosing, most of the research I’ve seen used 20-30 mg/70 Kg with better results at 30 mg/70kg doses. My one word of caution is that I do not believe these medications are “disease modifying.” What I mean by this is a patient may still be prone to having another depressive episode in the future. Psilocybin may increase the length of time between depressive episodes and require less frequent dosing which is a major improvement over daily oral medication for depression I’m not convinced by the data that using this medication will cure psychiatric and substance use disorders but I’m excited to see what the data will show when it’s widely available. Appreciate the interest and comment about psychedelics and I’m excited about the potential.
@@ShrinksInSneakers thanks!! I have a master's in clinical psychology but found out I really enjoy pharmacology, so thanks for your channel.
@@ShrinksInSneakers what would you suggest to someone who is essentially trapped on ssris but wants to try psilocybin? I desperately want to ween off so I can try it, but have had no luck for years due to withdrawals.
@@zila626 I always taper in my practice and sometimes you need a very slow tapper over several months to effectively come off. In some cases switching to fluoxetine can help due to the long half-life and less potential for withdrawal. If you haven't watched the video I did on Psilocybin you should it's paced with good information and the latest research. If you haven't subscribed please do and help me spread the word
What do you recommend after 22 ECT treatments did nothing, Ketamine did nothing. What about VNS. The only thing I haven’t done is MOAI due to the restrictions.
I think it's more about changing the mindset at that point. When I work with people we start to shift our focus from remission to, how can i live with theses symptoms and still function at a good level. VNS and BDS are major surgical procedures so carefully consider those options with your doctor. These procedures are still not disease modifying so there is still the risk of having another depressive episode. I just covered MAOIs in my latest video it should give you a good idea about the medication and dietary restrictions which are not too bad in my opinion. Hope this helps
My therapist tried 10 types of antidepressants, but still no hope😞
I just wanna know how life feels like without depression, like other people,can they really feel "joy" ? I forget how that feels like
Please talk with your doctor as I cannot offer any medical advice just general information for education. After 5 trials of medication pharmacotherapy is unlikely to result in remission of symptoms, not to say there is not value but there may be some residual symptoms that always linger around. In those cases things like ECT, TMS, and ketamine can be considered and if they are not options then the next step is asking how can I live with some residual depressive symptoms and still be safe and productive? I think it's possible and there is always hope. Hang in there
I tried everything as well. Then tried Ketamine Infusions, expensive and worsened my anxiety. Then I read about Symbyax ( Prozac and Olanzapine) and I felt much better. Didn’t last long, only 3 months then back to depression.
Give Symbyax a try if you haven’t.
I've been on at least 20 different medications, SSRI, horrible things like olanzapine (ruined my physical health and worsen my mental health), currently on Venlafaxine which it has been what makes me feel a more tolerable kind of depression. I rather live and die in this gloomy state than consent ect. I would never allow that.
It's a difficult place to be. I think there are still options and talking with your doctor about other potential medications, or procedures is worth it. ECT has it's down sides, mainly the memory disturbances but it also has the best efficacy for the treatment of depression. It's always hard and careful discussion about all options is most important
why do they say the TCA's like Nortryptiline are good for people failing many meds, and Lamictal etc. Seoquel works for me at 75mg for some sedating properties but weight gain and blood pressure are a concern. Thats not asking for advice but.. isnt TCA just a more potent SNRI?
The binding properties will differ depending on the mediation. In some ways TCAs are like SNRIs but they will not have the exact same properties and many SNRIs are less potent norepinephrine reuptake inhibiotrs, for example Effexor does not start working on norepinephrine until 225 mg is reached. I did a whole video looking at which SNRIs have the most effect on norepinephrine. Hope this helps
I am at stage 5 with more than 5-7 failed meds. and cocktails. i have also done, with no success at all TMS. now i'm at Ketemine and ECT, neither of which is covered by insurance???
There is always hope. Medications at this stage are unlikely to result in full remission but they can still help, and maybe we start to change the mindset to how can I live a good life even if I have some symptoms of depression. I hope this helps, if you haven't subscribed to the channel please do and spread the word about what we are doing here.
@Shrinks In Sneakers Thank you Sir for your concern. unfortuantly it you have ever had Treatment Resistant Depression/anhedonia maybe same thing, and tardive dyskinea which eliminates antisycotic meds. what you say is not possible, you cannot live with flatline emotions and feelings. ETC or deep brain messsage is all that left except suicide
I've got TRD have tried medications,Spravato,TMS,now I'm gonna try ECT.I'm afraid I'll never going to get well.
I think I talked about it in the video, but after 5 medication trials there seems to be very little evidence that another medication is going to solve the problem. At that point the mindset changes from finding total relief of symptoms to how can I live with these symptoms and still be functioning well and living my life. It's not giving up just changing the thinking around treatment. There is so much more to this, possibly it's not a biological issue at all, there are many causes of depression and many ways of approaching treatment. I think the biggest mistake we made with depression was lumping them all into one category of major depression. Hope this helps, if you haven't subscribed to the channel please do and spread the word about what we are doing here.
@@ShrinksInSneakers Thanks for the response.So you're saying there's a chance that I'll never achieve remission?
@@user-xb3vl2gs7g I don't know your case so I can't comment specifically but in my experience sometimes changing the goal from remission to how can I deal with this actually helps people get better. There is a lot of pressure if the goal is complete remission. It doesn't mean you shouldn't get treatment and all is lost
I've been on about 3 dozen different medications over the last 20 years to try to combat my trd. Ketamine has been an absolute God send for me. What are your thoughts on Interventional Psychiatry? Maybe you could make a video on it! I feel like it's a psychiatry subspecialty that not many are familiar with
We will talk about DBS and vagus nerve stimulators
Would you consider a trial of venlafaxine 75-225mg over 11 weeks adequate if the symptoms don't improve in the slightest and instead keep getting worse (I know the max. dose is 375mg)? When I started 150mg (1month on this dose) my depressive symptoms gradually became worse and at 225mg (over 3 weeks) it became a disaster. I was on 37,5mg for about 3 weeks, 75mg - 4 weeks, 150mg- 4 weeks and 225mg-3 weeks. Prior to that I was on vortioxetine (my first antidepressant trial, chosen because of cognitive issues) 5-20mg over a span of 20 weeks with no improvement whatsoever. Would you consider these 2 failed trials? My emotional numbness, apathy and anhedonia seemed to get worse with increasing the dosage of both medications. Soon I will be visiting a new psychiatrist and was wondering is it even worth trying an SSRI on its own as the 3rd option? Sorry for this long comment, love your videos :)
This sounds like failed trials based on the duration and dose of medication. For mild/moderate chronic depressed mood you have to question if it's a personality trait on temperament in which case it would respond better to psychotherapy possibly CBT. In general we are talking about severe depressive episodes unresponsive to treatment. Many factors will determine which treatment is right for a given person. If speed of recovery and rapid remission is the goal ECT or ketamine may be options. Hope this helps, appreciate the comment
You guys are straight up guessing.
I'm on mitrazapine, venlafexine, olanzapine, clonazepam, etizolam, lithium, Bupropion and propapanol and nothing is working 😭😭😭 suicidal ideation not going 😭😭
My doctor just put me on drugs 😭
see my previous response
I heard it's 2 trials, never heard of 5
Failure of two adequate trials would define treatment resistant depression. What I’m describing here is a longer algorithm for the treatment of TRD. I defined it at the beginning of the video as failure of at least two trials, but it’s not uncommon for patients to fail more than two trials and after about 7 trials based on the research medication is unlikely to work. At that point it’s more about strategies to cope with the depression understanding that complete remission is unlikely. Hope this helps
Meanwhile I’m still depressed …because all these 5 thing’s haven’t worked .iv spent what little money I had 🤨 now I’m broke and depressed … in Western Australia one cycle of ECT will cost you. At least $1500 dollars 🤯 .
This is not medical advice, and it's only for educational purposes. Please talk with your doctor before making any changes. I think there are a few things to say here, once someone has had 5 adequate trials of medication it's clear at that point that medication is unlikely to fully solve the problem this has been validated by one study. At that point either ECT or ketamine are the best options. I understand the struggle with getting things covered and essential treatments like ECT. I do not think health care anywhere is perfect and there are certainly disparities based on finacial circumstances. I think the other important thing to change is the focus from remission to "how can I live with these symptoms and still have a productive life?" There are ways to still have a good meaningful life even with depression. I think it's important to remain hopeful that things can get better. This does not mean that medicine will not be helpful it's just a different way of looking at things. I hope thins helps, if you haven't subscribed to the channel please do, and spread the word about what we are doing. I'm happy to answer an additional questions
I'm sorry but how is that fair
The side effects of most antidepressants are worse than the depression itself
Why don’t psychiatrists recommend adding magnesium supplements to their patients when trying to treat treatment resistant depression?
Is it not true that magnesium helps block nmda receptor just as the same way ketamine does? And isn’t there any truth that depression could possibly be related to inflamation? since magnesium taken at a correct dosage could work as a anti inflammatory as well and help the inflammation as well?🤷
I do know when I take epsom salt baths they leave me more alert and less depressed but eventually wear off. But I never had any results taking pill form because I don’t think we fully ingest the magnesium Like we do if we were to from a magnesium lotion or bath salts?
I would say most psychiatrists would be fine with someone adding a magnesium supplement. The problem with supplements is they are largely unregulated and purity and potency of products varies greatly. The other answer is often people have tried complementary and alternative medicines which is usually why they are coming for an intake in the first place. I like the idea of adding diet, exercise, and CAM therapies but they are unlikely to result in remission for patients with true TRD. Hope this helps, if you haven't subscribed to the channel please do and spread the word about what we are doing here
Great thanks for responding. Dig your channel and subscribed!
Do you offer consultations via zoom for a fee?
@@karmaline I'm not doing anything like that right now but you never know what the future holds. I appreciate all the support
Dude what about exercise ?
Diet ?
Or life situations?
I've covered all those things in other videos. All lifestyle interventions have value and should be added to treatment, I generally incorporate supplements, exercise and diet for everyone. However, lifestyle alone is unlikely to help those with severe depression, what we are talking about in this video is treatment resistant depression, people who have already done all the things you listed and tried a few medications but still have not reached remission. For mild to moderate depression start with CBT and lifestyle interventions first line and only move to medication after these things have been tried. All the research indicates the same trend, as severity increases medications separates more and more from placebo. Hope this helps, If you haven’t subscribed to the channel, please do and spread the word about what we are doing here. We also have daily content on Instagram @Shrinks_In_Sneakers
Dude, if you're mired in depression that's lasted for decades and has ruined or attenuated every relationship you've had with anyone who's ever cared about you, that has caused your enthusiasm for anything other than sleeping to evaporate, and has taken any available energy you manage to force out of your destroyed will simply to get out of bed and fake your way through a workday, exercise isn't an option. You might as well suggest that I take a trip to Saturn. Intense physical exercise is the best antidepressant ever - I agree with you 100%. The trouble is I'm not 17 and I don't have Infantry School Drill Sergeants compelling me to do grass drills in a mud pit for three hours. Getting past that soul crushing monster to go for a 20 minute walk is a prospect even less realistic than becoming a Korean pop star (in my hopelessly gakked brain anyway).
@@wes11bravo just start wherever you are ... Start with 1 min of exercise
Start with 1 pushup
I get what your saying but if I pulled myself out then anyone can because I was super FUBAR
That’s all good and well if you have the financial resources to spend on Dr’s and medications. And to pay for psychologist . But when you are struggling to pay your existing bills . And you already don’t drink smoke or have a social life ….where am I going to get the money to pay for this help ? 🤯 . Iv been dealing with this T.R.depression for decades ….in the past when it gets to critical mass I’ve , gotten help ….but that has depleted what little funds I had . Now my mortgage gets bigger by the day . And the family pressures are crushing Us . So what’s Your suggestion now ? 🤨 . These airyfairy advertising things are so bloody frustrating . You can find help if you have the money …. Less and less of us have the money day bye day . NOW WHAT ?? In Australia the medical system is linked to the insurance data base …. When I let my life insurance lapse because I couldn’t afford to renew it …. Then tried to get another life insurance policy a few months ago .my premium,s were going to be more expensive because of my mental health records. So now I still can’t afford life insurance. GREAT 🤨🤯 now if something happens to me my family has nothing 🤯 . HOW CAN I FIX THAT ? 💰💰💰💰💰🤨.
See my other response for more detail, but here in the states I can get people ECT without issue even with government insurances. I do understand the struggle associated with getting care covered, noting in medicine is easy and unfortunately there are disparities in all medical services related to socioeconmic factors. I know it's hard but hang in there keep fighting, good things can still happen.
This is why we need "social" care, not just individual. So many of us are depressed because there is something "right" with us- our society is broken and we can't ignore it like some. Putting my plug in here for universal basic income even if it's a long way off
@@zila626 I agree that there is far more to mental health than just medication and psychotherapy. Housing first initiatives, living wages, affordable healthcare all play a role. I will keep advocating for these things on my end, please do the same
Tried 14 different stupid medications and talk therapy, counselors, whatever. Nothing has worked and you want me to trust you to shock my brain? Oh hell no.
Saved me 3 times . I'm begging for it in UK but won't let me have it till I've suffered through several months of crippling depression pain anxiety
Side effect profile is a bit more robust? Are you kidding me? Depression treatments are a joke.
Dr. I need your opinion about a patient taking vortioxetine 20mg+effexor225mg+ +Modafinil400mg and recently added Abilify 10mg and made him very good first 2 week but began to sink down and now not that good
I'm not a psychiatrist but I can suggest combining the Effexor with Remeron instead of Vortioxetine. That combination, though risky, garnered the moniker of "California Rocket Fuel" due to its effectiveness. I've improved significantly on that combination but could still use another adjunct medication, like Modafinil, to help with residual cognitive dysfunction and anhedonia.