I appreciate this deep dive into this topic as someone with TRD, and had been written off by my previous psychiatrist as “there is nothing more to try “. And that fatigue is “just” depression. Yet it was not until the diagnosis of ME/ CFS by my psychiatrist, that explains why my fatigue on it’s own is disabling. You coverage of this topic should give anyone with TRD the courage to continue keep seeking help.
great video; thank you! I have one patient with core anxiety symptoms from early trauma and have OCD, anxiety, depression, and Complex PTSD. The patient doesn't have the ups and downs of bipolar or bipolar spectrum, but chronic jitteriness and these other disorders. Hoping to provide that patient some relief and i've been impressed how functional he is inspite of his challenges. Fingers crossed. Appreciate your contributions to the community.
There is a lot going on in that case. Given some of the things we talked about like the influence of trauma on medication management I would consider this a complex case and try to identify in some type of hierarchy treating first what you identified as the most severe and debilitating symptoms. with complex PTSD a good trauma based psychotherapist is going to be essential. Hope this helps
@@ShrinksInSneakers Many thanks! in full disclosure, the patient is myself. :-) I've been on almost all the SSRIs--high dose-- with marginal, if any, benefit. I've also tried to get on the atypicals and have tried Wellbutrin, ketamine, lamictal, and transcranial magnetic stimulation. And of course, therapy for over 35 years. I do think the SSRIs have waned in efficacy for me over the years. Will try to add Abilify to the Zoloft to see if it makes a difference. I don't like sedating medications as i have a high-demand job; but would welcome a little relief in the mood-anxiety-OCD realms. Anyway, thank you again. Do you know of any good clinicians such as you in the Washington DC, USA area, or do you ever do consults virtually? My biggest challenge was the severe, prolonged early childhood trauma; my Adverse Childhood Experience test was 10/10. I'll keep at it. Thank you again.
@@garysimone4977 I feel like you're describing me. I have the exact same issues! Got diagnosed with ADD too because of the jittering. I feel extremely uncomfortable with sitting still. ADHD meds help with this. How's your patient?
Doc, I am new to your channel, but I am very thankful for your content and straightforward approach. I've only listened to two videos so far, but I have learned a great deal. Thank you for sharing your information and expertise with us.
In Britain, CBT waiting lists can be longer than a year on the NHS. Oftentimes, medication is the first line treatment. I was initially diagnosed with severe GAD and major depression. I had been telling Doctors I was not depressed. Years after ineffective treatments, I was diagnosed with Bipolar 1. Finally I was given the most appropriate medication. Then the "depression" which did not respond to any of nine or ten different antidepressants, did subside. Anxiety did not go away, but I learned to manage it naturally. I have stayed away from hospitals for some years now. It means a lot to us to receive correct diagnosis and treatment. Makes all the difference! Thank you.
I have been taking Paroxetine for 5 years and it has helped me a lot, for both my depression and anxiety. Escitalopram didn't work for anxiety at all. I did not tolerate Fluoxetine, Sertraline (diarrhea), duloxetine (severe induced tinnitus) nor vortioxetine (nausea).
I am treatment resistant, suffered with mental health disorders since I was 15, I’m 29 now. Tried 33 medications, ECT and psychotherapy. I don’t know what to do anymore, I want my life back.
It's a hard place to be, in these situations we tend to focus more on how can we live with the depression as chasing remission might be resulting in more depression especially as the number of treatment failures increases. I never think of this as hopeless, it's more of a shift in focus and thinking. Hope this helps
I triyed everything and I didn't response to anything. The only medications that are giving me remission right now are Phenelzine plus lithium plus + t4. Ect give me remission but only for one month. I'm a fitness guy, so before medication I tried everything natural possible and psycotherapy too. Sorry for my English, I m italian.
"As this medication trials build up, the person becomes more resistant to depression". Do you have any evidence to support this? The truth might be that these persons have strong depression resistance to medication to begin with. I don't understand how trying a medication that fails can make depression worse. Also, some medication can prevent symptoms from worsening, even thought they aren't able to reverse the illness.
I agree that psychotherapy doesn't prevent resistant depression nor does it really treat it. Same with being outdoors and exercising etc. All the arm chair "experts" are full of it. What they don't understand is that just like a neurological condition like MS you can be outdoors all you want, if the myelin is being attacked then the symptoms will be there to differing degrees and ain't no therapy going to treat it. What therapy does do help is teach how to deal with the symptoms, to recognize them earlier and maybe seek treatment earlier, to help reframe self judgemental/critical thinking, to understand not all thoughts define us, to accept limitations and roll with it all better and also in the US especially deal with the stigma associated with mental health issues and probably most important is how to engage in relationships most effectively in the context of major recurring depression -- how to keep those in tact as much as possible and how to build empathy for those in ones life who have to see you suffering and how that impacts them without self judgement for having that suffering. The "experts" discuss people who have the ability to overcome minor or even moderate depression with exercise, diet, nature, etc. They can do that because they can do that. Not everyone can. The childhood trauma piece in particular is iust a killer for self treating major recurring depression. In my mid 40's I was rage biking 200 miles a week sometimes sobbing doing 5000 ft climbs and 50 miles at time. It didn't do anything for my depression. In fact it made it worse because it became evident there really was and is nothing I could do, eat, try that I hadn't tried that would work even with anti-depressants and stimulants for trauma/ADHD symptoms. So therapy saves vital relationships and helps people cope with the crushing realities of major depression but it doesn't do anything really for the overall symptoms of it in my experience.
Okay, it’s a very individual thing. I’ve been depressed for decades, and this last year has been hell. Everyone is different. Don’t slam others for sharing what works for them. They are not specifically telling YOU personally what to do.
Only slammimg those armchair "clinicians" who assert severe depression is a matter of willpower or not getting enough exercise or not eating right. If things like exercise or eating differently work for people that's awesome -- but don't make claim that they will work for the majority of those with severe depression because they don't 99% of the time and can actually worsen depression based on self criticism. Hope your symptoms mitigate soon and you find some peace.
I haven’t seen this question asked (or answered) anywhere. I'm a patient on venlafaxine-mirtazapine (75 mg - 45 mg). Even with the combination 37.5 mg - 45 mg I felt a big improvement in my symptoms. Bumping the venlafaxine to 75 seemed to improve things even more. How do I know whether there will be further improvement going up in my venlafaxine dose or not, or whether to ask my doctor about adding a medicine like aripripizole to increase dopamine in the body to see if there's further improvement possible? (I believe I experiences tinnitus on wellbutrin before, so would that have a similar effect?) I feel I enjoy life more than in the past and am calmer than before. I rarely feel irritable now (was worse before when just on mirtazapine). I still don't feel motivated to do much, but maybe that will come later. So how does the patient and doctor know when the desired result is reached, and it's not worth looking for further improvement?
The combination of effexor/mitazapine has been championed by Dr. Stephan Stahl, a UCLA psychiatrist, who refers to it as California Rocket Fuel. His text on psychopharmacology is excellent.
I think it is very significant that the response rate for placebo is so high. If the response to placebo is upwards of 37% (not far behind the medication response rates) then can we assume that ~37% of the 53% of the medication responses are also just placebo? Would it be fair to interpret this as follows: if someone opened up a psychiatry office across the street from you and followed all the same protocols but instead of using medication they gave the patients sugar pills then that office would likely acheive a 37% remissions rate? Am I doing the math correctly? Thanks again for taking the time to share your expertise!
In clinical practice you get the medication benefits and the placebo effect as well. Thesis not a bad thing we want to use all the tools that help people get better. The 37% is with the first medication trial, with augmentation and continued treatment the remission rates reach 67%. While placebo responses in psychiatry are high the medications still outperform placebo. The upshot for all this is we should be reserving medication for severe depression and trying other measures like psychotherapy first.
I have been taking Paroxetine for 5 years and it has helped me a lot, for both my depression and anxiety. Escitalopram didn't work for anxiety at all. I did not tolerate Fluoxetine, Sertraline (diarrhea), duloxetine (severe induced tinnitus) nor vortioxetine (nausea).
@@ShrinksInSneakers I understand that we need to do everything we can to help patients, and by any means necessary. Lately, many psychiatrists have been defending medications by making statements such as "...though we may not know how these medications actually work in the brain, we do know that they do work...sometimes." And maybe that is all we can do for now. But, I can't help but wonder about the mechanism of action of placebo. You also mentioned that depression may be cyclical and that many patients will reach full remission without intervention of any kind. As a sufferer of TRD, and being on my last legs, so to speak, I find all of the uncertainty / ambiguity in the field of psychiatry to be both horrifying and frustrating. There is no one to blame, I am just giving you a patient's perspective. It is what it is - it is just a reflection of our limited understanding of the human brain at this time. I am sharing the following questions and insights, as a long-time patient of MDD, in case they may provide fodder for your future videos. 1. Would the patient population that received placebo have had the same response / remission rates without the placebo? In other words, is the placebo pull itself necessary for the placebo effect? 2. What percentage of the patient population would have achieved response or remission with no intervention? 3. Of the 67% of patients who do eventually reach remission with medication, what percentage achieved remission not due to the medication but instead due to the placebo effect or because their depressive cycle ended on its own? 4. What portion of the 67% of patients who achieved remission were diagnosed correctly with MDD (verses other milder or more transient variants of depression)? In other words, what is the true efficacy of the current standard of care for properly diagnosed MDD patients? Perhaps an unanswerable question at this point with so many unknowns. I think it would be very helpful to explore the etiology of depression further as well. I suspect the diagnosis of "depression" is simply a label applied to a subset of self-reported, subjective symptoms, but that the root causes for these symptoms may be very different for different people. For example, if I go to the doctor and complain of a backache it could well be due to a slipped disk, a pinched nerve, a bone spur, a pulled muscle, a torn ligament, cancer, kidney problems, etc. In such a case, the doctor would be able to perform tests to correctly identify the root cause of the vague symptom of "backache" and thus treat the appropriate underlying physiological disfunction. With depression, there does not seem to be any reliable method of differentiating between (potentially) multiple root causes for the same symptoms. I would also love to get your thoughts on the emerging science around genetics and mental illness, particularly as it pertains to diagnosis and prediction of response. An example paper is titled: "The association of COMT genotype with buproprion treatment response in the treatment of major depressive disorder". Thank you again for all that you do. I genuinely appreciate your channel and all of the information and insight you share.
Thank you so much for the knowledge and the effort that you put in making these videos. They are so enlightening . I have been struggling with depression and anxiety for over twenty years and it is mainly due to my personality traits. In your experience what kind of medicine is more suitable in those cases?
I took escitalopram then citalopram for a total of 17 years without any problems. Then I stopped taking it for a few months to see if I still needed it. I tried to start taking it again but the side effects are horrible now. I tried 2 more SSRIs and 2SNRIs but they all give me horrible side effects. How did I take a SSRI for so long with no issues now I can’t?
It’s the number of failed trials that increases resistance. The more medications that are tried and failed after adequate dose and duration the more likely someone is to be treatment resistant
I have atypical depresstion (a bit bipolar.) When i take antidepressant it works for few months then it poop out, then i have to try different antidepressant to work for few months then poop out again, and so on, and after 6 or 8 months i go back to the first one again. Will that make me treatment resistance? Thank you very much
@@michaelelnaggar242 This is not medicinal advice, I'm not your doctor and you should talk with your doctor before making any changes. This information is for educational purposes only. My point in the video about treatment resistance is as more treatments failed the more resistant. There is a concept of bipolar III that says quick initial responses to antidepressants followed by quick loss of efficacy, in those cases treatment should be as bipolar with no antidepressants.
I’ve failed over 10 medications and my doctor has recently decided to put me on an maoi, parnate to be specific. I’m sort of scared tbh, especially when hearing about the diet restrictions. I think my symptoms are more related to depersonalization rather then pure depression so I don’t think the parnate will help much at all anyway…
Been on that med too ...I've responded poorly to every class of psyche meds over 30 yrs including ketamine and deep magnetic stimulation. Wont touch ECT. DOCs keep trying the same tx over and OVER. Parnate is poison to me. MAOs, specifically parnate had an antianxiety effect but made me look 6 months pregnant and caused light bleeding from both places - down there. Nothing works for me. Im a lost cause. I eat super clean and exercize when not in full blown episodes. On disability now for past 7 yrs - diagnosis? Mood disorder Not otherwise specified. I fantasize abt (unattainable) neurolink treatment- being my golden ticket... Hoping the best for you. Its a terribly rough journey
Long term major dep and been on almost every antidepression treatment there is. Parnate was one of the most effective of all for me. I had so much energy and felt so much better, but like all that do work it eventually stopped working. The dietary restrictions weren't that difficult, especially given how helpful it was. After decades struggling with it, I have come to believe that even the best meds provide only a small benefit. Lifestyle along with really taking a close look at patterns of thinking and addressing those give one a much better foundation of wellbeing upon which medication or anything else can better assist.
I still think everyone has to be discussed individually. The causes of depression are different for everyone. If you insist on using statistics and other people's research to apply to another person, then it will be difficult to really understand that person. I think the medical treatment in this social culture does not respect people's hearts. What if the real cause of depression was a problem of the heart rather than the brain? This is worth thinking about. Wouldn't it be wrong to keep the focus of research on the brain?
The important point you are making here is that research helps to guide us in general. It puts some science behind the treatment recommendations and tells us that in a population of depressed people we can expect this response. However, everyone is an individual and every case will demand different approaches to treatment. I think I personally do what you are talking about here in my clinical practice and I've said in other places that psychiatry is art rooted in science so you need to be a little bit of an artist to practice well. Hope this helps
@Shrinks In Sneakers a art !!!!! ..really, is the DSM BASED ON ONE SCIENTIFIC STUDY JUST ONE.. NO...DR YOU MEAN WELL BUT CALL IT LIKE IT IS IF PSYCH MEDS HAD A HIGH SUCCESS RATE WHY IS DEPRESSION A WORLD WIDE DISASTER
Hello, I tried exercise and I enjoyed it but it didn't prevent my next depressive episode. I tried 3 different psychotherapists well it ended up in a S. attempt. I've had escitalopram, bupropion, lamotrigine and brexpiprazole for two years now but it seems that they stopped working. I've tried cariprazine, Abilify, quetiapine, mirtazapine, and vortioxetine before. My mood cycles between depression and months when I'm elevated and convinced that I solved all my problems. I don't have reduced sleep so they don't think I have mania. I don't have psychotic elements. I've seen countless psychiatrists and some thought I had BPD but they also scratched that. Is it possible to have bipolar without reduced sleep? I oversleep all the time. Thank you for your videos!
I grew up in Williamstown and both my mother and sis worked at Cooper- wish I knew where your practice was because I would definitely see if you take my insurance! 😊
It would be good if patients could have more choice as to what drugs they want to try based on the side effects they wish to avoid without having to go through repeated trials of things that give intolerable side effects.
If you can't have that discussion with your doctor maybe it's time to get a different one? It's your body and wellbeing. If they're not listening to you and allowing you to make the final decision based on those things that are important for you they're not really doing their job, imho.
Love ur u tube hash tag or handle strinks in sheakers. I have a couple of questions I have depression and anxiety and have a history of eating disorders since teen years basically anorexia nervosa and bullimia nervosa . I had anorexia first and started to recover then unfortunately developed some issues and developed bullimia and had that for years until about 10 years ago and got in recovery again and had to regain weight again, it was rough but got better over time with help of dietitian and therapy. Anti depressants have been prescribed for my depression and anxiety but because of eating history iam scared to take these mds . I heard they all cause weight gain. Is this true and if not which ones don’t? Sorry for long story but nessary. Thank you for any reply
The problem with antidepressant medication trials is that nobody has exactly the same brain chemistry and there's a lot that is not known about the brain, so they don't hold much water. I have had way more negative side effects from antidepressants ( I just call them effects) than positive effects. I've given up on them. I have started treating myself with psilocybin out of desperation which really helps but does not work for my extremely bad anxiety. I believe I have Avoidant personality disorder and can't afford to see a psychiatrist and need anti anxiety medication. My psychologist said giving my disorder a name won't help so once again I have to try and fix my problems myself as doctors in Australia will not give people anti anxiety medication as it can be habit forming. American doctors seem to be a lot more understanding. I know what works for me and have had to buy them on the street and I can't always get them, so it's extremely frustrating. I know more about the medication than the doctors do and I'm tired of having to sneak around getting medication illegally when I can, paying a fortune for them as the one person I get them from knows how much they help me so takes full advantage of this fact. I feel like telling my doctor I take the medication you won't give me anyway and I don't have any urge to abuse them, it just really upsets me. That's my rant, sorry guys.
Aus here too. Now I'm a lot older, the gp is willing to allow me a few diazepam each month. Having had lifelong severe anxiety (and depression) I know what you're talking about with the difficulty in getting meds to help. Problem with benzos is the tolerance develops so quickly, and withdrawal is awful. Personally, after dealing with these things for decades, I've found meditation, yoga, examining and addressing negative thinking patterns etc to have given me the most benefit, by far. If you have avoidance issues - my unsolicited and unqualified advice would be to try a more exposure therapy approach for yourself. The more you are forced to interact with people the better you get at it and the less anxious you will become eventually. There is no magic bullet medication anywhere ever! What really makes a difference is addressing your issues. The anxiety and depression will probably always be there to some extent, if that's how you're wired, but you can change yourself in ways that make it a lot less debilitating.
@@lucydayLucida cheers 👍 I'm saving money to see a psychiatrist at the moment, I get what you mean about the tolerance thing but that's where I think the doctors should allow some dignity of risk, just don't take them everyday it's simple. I'm going to be on some form of medication for the rest of my life anyway, I'm 43 now, they should just give me what I know works. Every time a doctor suggests a new drug to me the chances are I already know someone who is on them and finds no benefits. Yeah meditation and breathing helps but its very temporary for me, Being diagnosed this late in life unfortunately CBT will more than likely not work, trust me I've read everything on the subject 😂 I was misdiagnosed with extreme depression despite telling them there's more to it, I was never believed and have resorted to fixing myself. Getting a proper diagnosis will be a start. Thank you for responding 👍🇦🇺
@@psilocyborg4775 I've found psychiatrists, especially older ones, a lot more willing to listen to what you know works or doesn't for you. Also a lot more willing to give benzos and stimulants. Hope you find something that helps. All the best
It is true: most people who fail pharmacotherapy are those people who have significant psycho-social factors that contribute to the development of depression, anxiety, etc. This is me! That's me! These are unemployment, social isolation, being single if you want a relationship, financial problems etc. These are the problems that are more common in today's modern world. Therefore, depression, anxiety and other mental illnesses become more prevalent and don't respond to drugs.
We have known for a long time that dopamine modulating medications can treat depression. I was a little surprised to see how much more effective they are compared to bupropion for example. The issue has always remains is side effect burden. As we develop new medications with lower risk of metabolic side effects we may see even more benefit.
@@ShrinksInSneakers Vraylar is proving hugely successful Problem is insurance but there are cards and discount cards to help patients out with the cost
I have been taking Paroxetine for 5 years and it has helped me a lot, for both my depression and anxiety. Escitalopram didn't work for anxiety at all. I did not tolerate Fluoxetine, Sertraline (diarrhea), duloxetine (severe induced tinnitus) nor vortioxetine (nausea).
A couple of issues I see with the way the data is being presented. First and foremost it's been shown that there's not really adequate blinding that occurs in these trials and often the researchers although technically blinded still know because of side effects whether or not someone's on an antidepressant medication. Secondly they're not using active placebos and and so people are more likely to believe their benefiting from a medication when they're experiencing side effects which enhances the potential response from the antidepressant medication. So really if you compare antidepressants with an active placebo there's not really a 16% difference an efficacy.. Third, the star d trial really just relies on repeated placebo effect for the efficacy of antidepressants. If we try someone on multiple trials of placebo they're going to have similar response and remission rates to those on antidepressants. So yeah I just don't find my research to be back for Quincy surrounding antidepressant medication. Furthermore we also have to account for side affects people are experiencing and after we account for that I just don't think I'm impresses are worth it
I appreciate this deep dive into this topic as someone with TRD, and had been written off by my previous psychiatrist as “there is nothing more to try “. And that fatigue is “just” depression.
Yet it was not until the diagnosis of ME/ CFS by my psychiatrist, that explains why my fatigue on it’s own is disabling.
You coverage of this topic should give anyone with TRD the courage to continue keep seeking help.
Thank you, it's a big topic and there was far more to say about treatment but I tried to keep it around 30 minute.
great video; thank you! I have one patient with core anxiety symptoms from early trauma and have OCD, anxiety, depression, and Complex PTSD. The patient doesn't have the ups and downs of bipolar or bipolar spectrum, but chronic jitteriness and these other disorders. Hoping to provide that patient some relief and i've been impressed how functional he is inspite of his challenges. Fingers crossed. Appreciate your contributions to the community.
There is a lot going on in that case. Given some of the things we talked about like the influence of trauma on medication management I would consider this a complex case and try to identify in some type of hierarchy treating first what you identified as the most severe and debilitating symptoms. with complex PTSD a good trauma based psychotherapist is going to be essential. Hope this helps
@@ShrinksInSneakers Many thanks! in full disclosure, the patient is myself. :-) I've been on almost all the SSRIs--high dose-- with marginal, if any, benefit. I've also tried to get on the atypicals and have tried Wellbutrin, ketamine, lamictal, and transcranial magnetic stimulation. And of course, therapy for over 35 years. I do think the SSRIs have waned in efficacy for me over the years. Will try to add Abilify to the Zoloft to see if it makes a difference. I don't like sedating medications as i have a high-demand job; but would welcome a little relief in the mood-anxiety-OCD realms. Anyway, thank you again. Do you know of any good clinicians such as you in the Washington DC, USA area, or do you ever do consults virtually? My biggest challenge was the severe, prolonged early childhood trauma; my Adverse Childhood Experience test was 10/10. I'll keep at it. Thank you again.
@Shrinks In Sneakers no kidding...wow
@@garysimone4977
I feel like you're describing me. I have the exact same issues! Got diagnosed with ADD too because of the jittering. I feel extremely uncomfortable with sitting still. ADHD meds help with this.
How's your patient?
Doc, I am new to your channel, but I am very thankful for your content and straightforward approach. I've only listened to two videos so far, but I have learned a great deal. Thank you for sharing your information and expertise with us.
In Britain, CBT waiting lists can be longer than a year on the NHS. Oftentimes, medication is the first line treatment. I was initially diagnosed with severe GAD and major depression. I had been telling Doctors I was not depressed. Years after ineffective treatments, I was diagnosed with Bipolar 1. Finally I was given the most appropriate medication. Then the "depression" which did not respond to any of nine or ten different antidepressants, did subside. Anxiety did not go away, but I learned to manage it naturally. I have stayed away from hospitals for some years now. It means a lot to us to receive correct diagnosis and treatment. Makes all the difference! Thank you.
13:37 I have never heard such wise words …
I have been taking Paroxetine for 5 years and it has helped me a lot, for both my depression and anxiety.
Escitalopram didn't work for anxiety at all.
I did not tolerate Fluoxetine, Sertraline (diarrhea), duloxetine (severe induced tinnitus) nor vortioxetine (nausea).
It has some serious risks though, severe sexual dysfunction, PSSD, severe withdrawal
I am treatment resistant, suffered with mental health disorders since I was 15, I’m 29 now.
Tried 33 medications, ECT and psychotherapy. I don’t know what to do anymore, I want my life back.
It's a hard place to be, in these situations we tend to focus more on how can we live with the depression as chasing remission might be resulting in more depression especially as the number of treatment failures increases. I never think of this as hopeless, it's more of a shift in focus and thinking. Hope this helps
@@ShrinksInSneakers thank you so much
@@Kingboo1081 no problem
I triyed everything and I didn't response to anything. The only medications that are giving me remission right now are Phenelzine plus lithium plus + t4. Ect give me remission but only for one month. I'm a fitness guy, so before medication I tried everything natural possible and psycotherapy too. Sorry for my English, I m italian.
"As this medication trials build up, the person becomes more resistant to depression".
Do you have any evidence to support this?
The truth might be that these persons have strong depression resistance to medication to begin with.
I don't understand how trying a medication that fails can make depression worse.
Also, some medication can prevent symptoms from worsening, even thought they aren't able to reverse the illness.
I agree that psychotherapy doesn't prevent resistant depression nor does it really treat it. Same with being outdoors and exercising etc. All the arm chair "experts" are full of it.
What they don't understand is that just like a neurological condition like MS you can be outdoors all you want, if the myelin is being attacked then the symptoms will be there to differing degrees and ain't no therapy going to treat it.
What therapy does do help is teach how to deal with the symptoms, to recognize them earlier and maybe seek treatment earlier, to help reframe self judgemental/critical thinking, to understand not all thoughts define us, to accept limitations and roll with it all better and also in the US especially deal with the stigma associated with mental health issues and probably most important is how to engage in relationships most effectively in the context of major recurring depression -- how to keep those in tact as much as possible and how to build empathy for those in ones life who have to see you suffering and how that impacts them without self judgement for having that suffering.
The "experts" discuss people who have the ability to overcome minor or even moderate depression with exercise, diet, nature, etc. They can do that because they can do that. Not everyone can.
The childhood trauma piece in particular is iust a killer for self treating major recurring depression. In my mid 40's I was rage biking 200 miles a week sometimes sobbing doing 5000 ft climbs and 50 miles at time. It didn't do anything for my depression. In fact it made it worse because it became evident there really was and is nothing I could do, eat, try that I hadn't tried that would work even with anti-depressants and stimulants for trauma/ADHD symptoms.
So therapy saves vital relationships and helps people cope with the crushing realities of major depression but it doesn't do anything really for the overall symptoms of it in my experience.
Okay, it’s a very individual thing. I’ve been depressed for decades, and this last year has been hell. Everyone is different. Don’t slam others for sharing what works for them. They are not specifically telling YOU personally what to do.
Only slammimg those armchair "clinicians" who assert severe depression is a matter of willpower or not getting enough exercise or not eating right.
If things like exercise or eating differently work for people that's awesome -- but don't make claim that they will work for the majority of those with severe depression because they don't 99% of the time and can actually worsen depression based on self criticism.
Hope your symptoms mitigate soon and you find some peace.
Vielen Dank für dein hervorragendes Video! 👍👍👍
Thanks appreciate it
I haven’t seen this question asked (or answered) anywhere. I'm a patient on venlafaxine-mirtazapine (75 mg - 45 mg). Even with the combination 37.5 mg - 45 mg I felt a big improvement in my symptoms. Bumping the venlafaxine to 75 seemed to improve things even more. How do I know whether there will be further improvement going up in my venlafaxine dose or not, or whether to ask my doctor about adding a medicine like aripripizole to increase dopamine in the body to see if there's further improvement possible? (I believe I experiences tinnitus on wellbutrin before, so would that have a similar effect?) I feel I enjoy life more than in the past and am calmer than before. I rarely feel irritable now (was worse before when just on mirtazapine). I still don't feel motivated to do much, but maybe that will come later. So how does the patient and doctor know when the desired result is reached, and it's not worth looking for further improvement?
The combination of effexor/mitazapine has been championed by Dr. Stephan Stahl, a UCLA psychiatrist, who refers to it as California Rocket Fuel. His text on psychopharmacology is excellent.
I think it is very significant that the response rate for placebo is so high. If the response to placebo is upwards of 37% (not far behind the medication response rates) then can we assume that ~37% of the 53% of the medication responses are also just placebo? Would it be fair to interpret this as follows: if someone opened up a psychiatry office across the street from you and followed all the same protocols but instead of using medication they gave the patients sugar pills then that office would likely acheive a 37% remissions rate? Am I doing the math correctly? Thanks again for taking the time to share your expertise!
No,you are not doing math correctly :D
In clinical practice you get the medication benefits and the placebo effect as well. Thesis not a bad thing we want to use all the tools that help people get better. The 37% is with the first medication trial, with augmentation and continued treatment the remission rates reach 67%. While placebo responses in psychiatry are high the medications still outperform placebo. The upshot for all this is we should be reserving medication for severe depression and trying other measures like psychotherapy first.
I have been taking Paroxetine for 5 years and it has helped me a lot, for both my depression and anxiety.
Escitalopram didn't work for anxiety at all.
I did not tolerate Fluoxetine, Sertraline (diarrhea), duloxetine (severe induced tinnitus) nor vortioxetine (nausea).
@@ShrinksInSneakers I understand that we need to do everything we can to help patients, and by any means necessary. Lately, many psychiatrists have been defending medications by making statements such as "...though we may not know how these medications actually work in the brain, we do know that they do work...sometimes." And maybe that is all we can do for now. But, I can't help but wonder about the mechanism of action of placebo. You also mentioned that depression may be cyclical and that many patients will reach full remission without intervention of any kind.
As a sufferer of TRD, and being on my last legs, so to speak, I find all of the uncertainty / ambiguity in the field of psychiatry to be both horrifying and frustrating. There is no one to blame, I am just giving you a patient's perspective. It is what it is - it is just a reflection of our limited understanding of the human brain at this time.
I am sharing the following questions and insights, as a long-time patient of MDD, in case they may provide fodder for your future videos.
1. Would the patient population that received placebo have had the same response / remission rates without the placebo? In other words, is the placebo pull itself necessary for the placebo effect?
2. What percentage of the patient population would have achieved response or remission with no intervention?
3. Of the 67% of patients who do eventually reach remission with medication, what percentage achieved remission not due to the medication but instead due to the placebo effect or because their depressive cycle ended on its own?
4. What portion of the 67% of patients who achieved remission were diagnosed correctly with MDD (verses other milder or more transient variants of depression)?
In other words, what is the true efficacy of the current standard of care for properly diagnosed MDD patients? Perhaps an unanswerable question at this point with so many unknowns.
I think it would be very helpful to explore the etiology of depression further as well. I suspect the diagnosis of "depression" is simply a label applied to a subset of self-reported, subjective symptoms, but that the root causes for these symptoms may be very different for different people.
For example, if I go to the doctor and complain of a backache it could well be due to a slipped disk, a pinched nerve, a bone spur, a pulled muscle, a torn ligament, cancer, kidney problems, etc. In such a case, the doctor would be able to perform tests to correctly identify the root cause of the vague symptom of "backache" and thus treat the appropriate underlying physiological disfunction. With depression, there does not seem to be any reliable method of differentiating between (potentially) multiple root causes for the same symptoms.
I would also love to get your thoughts on the emerging science around genetics and mental illness, particularly as it pertains to diagnosis and prediction of response. An example paper is titled: "The association of COMT genotype with buproprion treatment response in the treatment of major depressive disorder".
Thank you again for all that you do. I genuinely appreciate your channel and all of the information and insight you share.
I think you're right, drug effectiveness is drug+placebo.
Thank you so much for the knowledge and the effort that you put in making these videos. They are so enlightening . I have been struggling with depression and anxiety for over twenty years and it is mainly due to my personality traits. In your experience what kind of medicine is more suitable in those cases?
Why isn’t rTMS or iTBS recommended more often by clinicians?
so basically if you don’t react to medicines your just forever screwed to relapse and feel awful a lot 😂😢
can you make a video on how to get and stay in remission? this video was discouraging kinda lol
I took escitalopram then citalopram for a total of 17 years without any problems. Then I stopped taking it for a few months to see if I still needed it. I tried to start taking it again but the side effects are horrible now. I tried 2 more SSRIs and 2SNRIs but they all give me horrible side effects. How did I take a SSRI for so long with no issues now I can’t?
Does changing antidepressant often make patient treatment resistant?
It’s the number of failed trials that increases resistance. The more medications that are tried and failed after adequate dose and duration the more likely someone is to be treatment resistant
I have atypical depresstion (a bit bipolar.) When i take antidepressant it works for few months then it poop out, then i have to try different antidepressant to work for few months then poop out again, and so on, and after 6 or 8 months i go back to the first one again. Will that make me treatment resistance?
Thank you very much
@@michaelelnaggar242 This is not medicinal advice, I'm not your doctor and you should talk with your doctor before making any changes. This information is for educational purposes only. My point in the video about treatment resistance is as more treatments failed the more resistant. There is a concept of bipolar III that says quick initial responses to antidepressants followed by quick loss of efficacy, in those cases treatment should be as bipolar with no antidepressants.
That’s me. Same thing happened with TMS
@@stevensicherman4101 Appreciate the comment, it's always good to have an understanding
I’ve failed over 10 medications and my doctor has recently decided to put me on an maoi, parnate to be specific. I’m sort of scared tbh, especially when hearing about the diet restrictions.
I think my symptoms are more related to depersonalization rather then pure depression so I don’t think the parnate will help much at all anyway…
Been on that med too
...I've responded poorly to every class of psyche meds over 30 yrs including ketamine and deep magnetic stimulation. Wont touch ECT.
DOCs keep trying the same tx over and OVER.
Parnate is poison to me. MAOs, specifically parnate had an antianxiety effect but made me look 6 months pregnant and caused light bleeding from both places - down there.
Nothing works for me. Im a lost cause.
I eat super clean and exercize when not in full blown episodes.
On disability now for past 7 yrs - diagnosis? Mood disorder Not otherwise specified.
I fantasize abt (unattainable) neurolink treatment- being my golden ticket...
Hoping the best for you. Its a terribly rough journey
Long term major dep and been on almost every antidepression treatment there is. Parnate was one of the most effective of all for me. I had so much energy and felt so much better, but like all that do work it eventually stopped working. The dietary restrictions weren't that difficult, especially given how helpful it was.
After decades struggling with it, I have come to believe that even the best meds provide only a small benefit. Lifestyle along with really taking a close look at patterns of thinking and addressing those give one a much better foundation of wellbeing upon which medication or anything else can better assist.
You should go to an expert psychotherapist, this is the most effective way
The fact that it is females who are more likely to be treatment resistant indicates to me that it could be related their hormones.
Are those records on your wall? If so which ones are they?
What are your thaughts on the recent study that found exercise had better results the a SSRI
What about using very low doses of mirtazapine together with Sri? or combine Sri with MAOi? I mean to try resistant depression.
I still think everyone has to be discussed individually. The causes of depression are different for everyone. If you insist on using statistics and other people's research to apply to another person, then it will be difficult to really understand that person. I think the medical treatment in this social culture does not respect people's hearts. What if the real cause of depression was a problem of the heart rather than the brain? This is worth thinking about. Wouldn't it be wrong to keep the focus of research on the brain?
The important point you are making here is that research helps to guide us in general. It puts some science behind the treatment recommendations and tells us that in a population of depressed people we can expect this response. However, everyone is an individual and every case will demand different approaches to treatment. I think I personally do what you are talking about here in my clinical practice and I've said in other places that psychiatry is art rooted in science so you need to be a little bit of an artist to practice well. Hope this helps
@Shrinks In Sneakers a art !!!!! ..really, is the DSM BASED ON ONE SCIENTIFIC STUDY JUST ONE.. NO...DR YOU MEAN WELL BUT CALL IT LIKE IT IS IF PSYCH MEDS HAD A HIGH SUCCESS RATE WHY IS DEPRESSION A WORLD WIDE DISASTER
Hello, I tried exercise and I enjoyed it but it didn't prevent my next depressive episode. I tried 3 different psychotherapists well it ended up in a S. attempt. I've had escitalopram, bupropion, lamotrigine and brexpiprazole for two years now but it seems that they stopped working. I've tried cariprazine, Abilify, quetiapine, mirtazapine, and vortioxetine before. My mood cycles between depression and months when I'm elevated and convinced that I solved all my problems. I don't have reduced sleep so they don't think I have mania. I don't have psychotic elements. I've seen countless psychiatrists and some thought I had BPD but they also scratched that. Is it possible to have bipolar without reduced sleep? I oversleep all the time. Thank you for your videos!
Hell Doc- what are your thoughts on Exxua aka Gepirone ER? I hear it will be available in June and has a different side effect profile than SSRIs do.
I grew up in Williamstown and both my mother and sis worked at Cooper- wish I knew where your practice was because I would definitely see if you take my insurance! 😊
I appreciate that, you never know a private practice might be in the future plans
@@ShrinksInSneakers Same here if you open one in Ohio.
It would be good if patients could have more choice as to what drugs they want to try based on the side effects they wish to avoid without having to go through repeated trials of things that give intolerable side effects.
If you can't have that discussion with your doctor maybe it's time to get a different one? It's your body and wellbeing. If they're not listening to you and allowing you to make the final decision based on those things that are important for you they're not really doing their job, imho.
I take Sertraline and escitalopram, I want to let them because after some years they don’t work for me at all
Love ur u tube hash tag or handle strinks in sheakers. I have a couple of questions I have depression and anxiety and have a history of eating disorders since teen years basically anorexia nervosa and bullimia nervosa . I had anorexia first and started to recover then unfortunately developed some issues and developed bullimia and had that for years until about 10 years ago and got in recovery again and had to regain weight again, it was rough but got better over time with help of dietitian and therapy. Anti depressants have been prescribed for my depression and anxiety but because of eating history iam scared to take these mds . I heard they all cause weight gain. Is this true and if not which ones don’t? Sorry for long story but nessary. Thank you for any reply
The problem with antidepressant medication trials is that nobody has exactly the same brain chemistry and there's a lot that is not known about the brain, so they don't hold much water. I have had way more negative side effects from antidepressants ( I just call them effects) than positive effects. I've given up on them. I have started treating myself with psilocybin out of desperation which really helps but does not work for my extremely bad anxiety. I believe I have Avoidant personality disorder and can't afford to see a psychiatrist and need anti anxiety medication. My psychologist said giving my disorder a name won't help so once again I have to try and fix my problems myself as doctors in Australia will not give people anti anxiety medication as it can be habit forming. American doctors seem to be a lot more understanding. I know what works for me and have had to buy them on the street and I can't always get them, so it's extremely frustrating. I know more about the medication than the doctors do and I'm tired of having to sneak around getting medication illegally when I can, paying a fortune for them as the one person I get them from knows how much they help me so takes full advantage of this fact. I feel like telling my doctor I take the medication you won't give me anyway and I don't have any urge to abuse them, it just really upsets me. That's my rant, sorry guys.
Aus here too. Now I'm a lot older, the gp is willing to allow me a few diazepam each month. Having had lifelong severe anxiety (and depression) I know what you're talking about with the difficulty in getting meds to help. Problem with benzos is the tolerance develops so quickly, and withdrawal is awful. Personally, after dealing with these things for decades, I've found meditation, yoga, examining and addressing negative thinking patterns etc to have given me the most benefit, by far. If you have avoidance issues - my unsolicited and unqualified advice would be to try a more exposure therapy approach for yourself. The more you are forced to interact with people the better you get at it and the less anxious you will become eventually. There is no magic bullet medication anywhere ever! What really makes a difference is addressing your issues. The anxiety and depression will probably always be there to some extent, if that's how you're wired, but you can change yourself in ways that make it a lot less debilitating.
@@lucydayLucida cheers 👍 I'm saving money to see a psychiatrist at the moment, I get what you mean about the tolerance thing but that's where I think the doctors should allow some dignity of risk, just don't take them everyday it's simple. I'm going to be on some form of medication for the rest of my life anyway, I'm 43 now, they should just give me what I know works. Every time a doctor suggests a new drug to me the chances are I already know someone who is on them and finds no benefits. Yeah meditation and breathing helps but its very temporary for me, Being diagnosed this late in life unfortunately CBT will more than likely not work, trust me I've read everything on the subject 😂 I was misdiagnosed with extreme depression despite telling them there's more to it, I was never believed and have resorted to fixing myself. Getting a proper diagnosis will be a start. Thank you for responding 👍🇦🇺
@@psilocyborg4775 I've found psychiatrists, especially older ones, a lot more willing to listen to what you know works or doesn't for you. Also a lot more willing to give benzos and stimulants. Hope you find something that helps. All the best
Do you mean twice a day 1000mg (not 1mg) Omega 3? What is more important: EPA or DHA?
It’s 1000 mg and in depression pure EPA or a 2:1 ratio of EPA to DHA is what you are looking for
It is true: most people who fail pharmacotherapy are those people who have significant psycho-social factors that contribute to the development of depression, anxiety, etc. This is me! That's me! These are unemployment, social isolation, being single if you want a relationship, financial problems etc. These are the problems that are more common in today's modern world. Therefore, depression, anxiety and other mental illnesses become more prevalent and don't respond to drugs.
I like the add on antipsychotics Abilify or Rexulti to increase efficacy
I feel sorry for your patients.
We have known for a long time that dopamine modulating medications can treat depression. I was a little surprised to see how much more effective they are compared to bupropion for example. The issue has always remains is side effect burden. As we develop new medications with lower risk of metabolic side effects we may see even more benefit.
@@ShrinksInSneakers Vraylar is proving hugely successful Problem is insurance but there are cards and discount cards to help patients out with the cost
I have been taking Paroxetine for 5 years and it has helped me a lot, for both my depression and anxiety.
Escitalopram didn't work for anxiety at all.
I did not tolerate Fluoxetine, Sertraline (diarrhea), duloxetine (severe induced tinnitus) nor vortioxetine (nausea).
@@ShrinksInSneakers Can you elaborate on this, as bupropion targets too the dopamine receptor.
19:35 I know …
Read the book The Copper Revolution by Jason Hommel.
A couple of issues I see with the way the data is being presented. First and foremost it's been shown that there's not really adequate blinding that occurs in these trials and often the researchers although technically blinded still know because of side effects whether or not someone's on an antidepressant medication.
Secondly they're not using active placebos and and so people are more likely to believe their benefiting from a medication when they're experiencing side effects which enhances the potential response from the antidepressant medication.
So really if you compare antidepressants with an active placebo there's not really a 16% difference an efficacy..
Third, the star d trial really just relies on repeated placebo effect for the efficacy of antidepressants.
If we try someone on multiple trials of placebo they're going to have similar response and remission rates to those on antidepressants.
So yeah I just don't find my research to be back for Quincy surrounding antidepressant medication.
Furthermore we also have to account for side affects people are experiencing and after we account for that I just don't think I'm impresses are worth it
How about the fact that psych drugs are at best 2% better per placebo per massive study out of England