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So my pdoc lumps me into the "treatment-resistant depression" category because the first antidepressant I took, Lexapro, partially pooped out on me. Is it just me or does that not seem like a rather liberal definition of treatment-resistant depression? Also, instead of trying another SSRI, he went straight to Cymbalta, which also strikes me as unusual, since Lexapro worked very well for me for about six months. After six weeks on Cymbalta and Wellbutrin with results very similar to the Lexapro and Wellbutrin combo I have been on previously (i.e., they are helping but probably not as much as they should), I am now adding Lamictal to my cocktail. Anyway, it's just kind of strange to me that he thinks this kind of aggressive treatment is warranted. I know he is just trying to get me feeling better, and I'm ok with it as long as my body can handle it, but still...a little weird given my really limited prior med history.

Have any of you been labeled as "treatment-resistant"? What definition does your pdoc use? Just curious.

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Sorry if I sounded skeptical. After doing an internship at the state hospital, I have seen how hard drug reps push new meds on pdocs and then it seems like docs start prescribing it to patients that may not necessarily need it. It's really kind of creepy.

I have heard that Lamictal is good at knocking out depression in BPI and II, but never heard about this treatment resistant thing.

To me, I've always conceptualized treatment resistant as like a diagnosis that gets used when an episode of depression does not go into remission AFTER trying many, many, many SSRIs and psychotherapy. For some reason I've always thought it required a long time to get that term used, and typically, I've always heard that ECT is the treatment for treatment resistant depression.

It's not in the DSM-IV as a diagnosis.

But yeah, just my 2 cents.

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Cocktails can sometimes treat what I term "turd" (TRD, get it?). I got out of it with Cymbalta + trazodone.

and by cocktails, I mean taking multiple meds (polypharmacy), not the use of alcohol =P

(Trazodone specifically acts against the 5HT2 receptor family, a group of serotonin receptors which for most depressed people actually lead to bad things. Some researchers are speculating this is why the first few weeks of SSRI treatment are rough and can result in worsening depression and/or suicidality.)

Of course, when I say I "got out of it" with Cymbalta + trazodone, by at least one pdoc's impression, it meant I got rocketed into hypomania. It was a euphoric one. Maybe it was the "real" me. Who knows. The me sitting here is almost as happy, save for life circumstances and parts of my brain dying off.

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Did you take the trazodone at night for sleep, Herrfous? That shit knocks me out. Only 25mg and I'm usually sleeping so hard that waking up is like waking up from a coma.

themind--what you said about how you think of treatment-resistant depression--that is how I think of it too. After someone has tried many meds and many types of therapy. That's why I thought it was weird that my pdoc said I was treatment resistant.

I'm not sure how much my pdoc is influenced by pharm reps, but I don't really get that vibe from him. From how old he looks he looks like he's been a practicing psychiatrist for a long time. He bases his decisions on how to treat from past clinical experience. I'm guessing he's seen a lot of patients not get and stay better from the SSRI go-round, so he uses a polypharmacy approach. He said the Wellbutrin and Lamictal are intended to boost the effectiveness of the Cymbalta (Cymbalta is the most important med for me because I need an SRI in some form).

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Did you take the trazodone at night for sleep, Herrfous? That shit knocks me out. Only 25mg and I'm usually sleeping so hard that waking up is like waking up from a coma.

themind--what you said about how you think of treatment-resistant depression--that is how I think of it too. After someone has tried many meds and many types of therapy. That's why I thought it was weird that my pdoc said I was treatment resistant.

I'm not sure how much my pdoc is influenced by pharm reps, but I don't really get that vibe from him. From how old he looks he looks like he's been a practicing psychiatrist for a long time. He bases his decisions on how to treat from past clinical experience. I'm guessing he's seen a lot of patients not get and stay better from the SSRI go-round, so he uses a polypharmacy approach. He said the Wellbutrin and Lamictal are intended to boost the effectiveness of the Cymbalta (Cymbalta is the most important med for me because I need an SRI in some form).

I did initially take it for sleep, but since I'm so drug-resistant, 150mg was the starting dose for sleep for me. Eventually, we got to 300mg and decided to try something else, since 300mg was an absolutely ridiculous dose for sleep... that's when I switched to Remeron.

I know that Remeron has made you obese, but part of it is that it induces sugar and carb cravings, but doesn't dork with your blood sugar per se, like Zyprexa or Seroquel might. Learning to not give in to these sugar and carb cravings (especially at night, where they're especially disastrous!) is key to successful treatment with Remeron. This is difficult, I know by personal experience.

And I'm glad your pdoc is experienced and smart (from what I garner). Lamictal has been dorked around with as an adjunct to AD treatment even in those who are not bipolar -- I guess it's not a surprise, since Lamictal is known as the antidepressant mood-stabilizer, often given to BP patients who are depression-predominant (a la moi).

Wellbutrin is another good choice for adjunct treatment... it works on dopamine and norepinephrine, though be careful combining it with Cymbalta/Effexor, you could get too much norepinephrine action and end up with side effects like orthostatic hypotension (i.e., blood rushing out of your head if you quickly stand up, causing you to stumble and/or faint).

Another fave as far as 5HT2 blockers (such as trazodone and Remeron) is Serzone (aka nefazadone), it's a pretty 'clean' drug save for the fact that in certain individuals, it tends to cause liver damage. And given that Cymbalta does the same thing, I wouldn't recommend it with Cymbalta. Effexor, on the other hand, I don't know. Please talk to your pdoc about this.

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Huh? I've never been on Remeron, and I'm far from obese! Did you confuse me with someone else?

Hey, do you know of any other effects that could come with too much noreph reuptake inhibition? Haven't read anything about it.

whoops, sorry hollywood. I have no idea whom I'm talking about. I swear someone around here complained about it. I'm starting to walking with a shuffle/limp, so I assume this "virus" or whatnot is in the process of impairing certain parts of my brain, including but not limited to the centers that remember who's on what. I forget now what I'm on (the pdoc visit in an hour will be interesting to say the least).

As for the NRIs, orthostatic hypotension is the biggest concern. Some people also get general hypertension (somewhat ironic, ain't it). Also, psychologically, compared to SSRIs, there is a greater incidence of silicovaginosis (irritability). Your mileage will vary.

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Hmm...I have treatment resistant Bipolar II, mostly depression. Tried over 15 medications, hospitalized four times in the last five years. Over 40 ECT treatments in the last five years, a VNS stimulator, lots of psychotherapy. Lost my job, my house, and sent my 15 year old sons to live with their dad. Even gave my dog away. On disability. THIS is treatment resistant depression. I'm feeling better now.

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of course being bp1 i cycle, but when i cycle into depression, it is what you would classify as "treatment resistent". nothing helps. no drug increases or additions, no exercise or psychotherapy, no friends or laughing, nothing. i've been to the hospital over it and have taken most of the drugs i've been on to curb it. too bad it takes just a cycle out, a natural cycle and not an induced one, for me to get out of it.

yes, sunshine's depression is the kind that they talk about when they say "resistent". nothing helped her. i'm not as bad nearly, but i can say that if i were unipolar, i'd be with sunshine. being bp and cycling out saves me in this case.

i'm not the pharma expert and can't contribute in any way to talking about your meds. i can say that i think that the SSRI class is great and that just because one drug doesn't work, it doesn't mean that others won't. my mom used to take paxil and it pooped out, so she started lex and it has worked for years (when she decides she needs to take her meds- bp1- that is).

i don't understand throwing in lamictal, except that unipolar depression also happens in cycles. you go from a baseline downwards, and up to the baseline, and the cycle continues. lamictal may be being thrown in to stop that cycling. i HAVE heard of it a few times. i've heard of atypical antipsychotics being used more frequently because they have higher versitility, but every pdoc and every patient is different.

sunshine lost it all, even her dog. there are others here too who have really gone through the treatment-resistent part. just trying a few drugs doesn't put you there. have no fear! you're not even close.

loon

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Hmm...I have treatment resistant Bipolar II, mostly depression. Tried over 15 medications, hospitalized four times in the last five years. Over 40 ECT treatments in the last five years, a VNS stimulator, lots of psychotherapy. Lost my job, my house, and sent my 15 year old sons to live with their dad. Even gave my dog away. On disability. THIS is treatment resistant depression. I'm feeling better now.

Talk about having to deal with a "turd". I genuinely feel sorry for you. I'm not going to suggest the cocktails I mentioned above, since you've probably tried them already. I won't lecture you on the med-go-round, since you've been on it longer than I have (3 years).

And I see you're taking Cytomel too... I assume this means you're hypothyroid? I am, too. sucky combo with the depression, can definitely cause turd.

Also, you did mention in another post that you live in South Carolina. That probably doesn't help, either.

hollywood--

I got you confused with another CBer who had a thread about Effexor+trazodone for a similar condition. That's why I thought Remeron had made you obese! my apologies.

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Hmm...I have treatment resistant Bipolar II, mostly depression. Tried over 15 medications, hospitalized four times in the last five years. Over 40 ECT treatments in the last five years, a VNS stimulator, lots of psychotherapy. Lost my job, my house, and sent my 15 year old sons to live with their dad. Even gave my dog away. On disability. THIS is treatment resistant depression. I'm feeling better now.

Talk about having to deal with a "turd". I genuinely feel sorry for you. I'm not going to suggest the cocktails I mentioned above, since you've probably tried them already. I won't lecture you on the med-go-round, since you've been on it longer than I have (3 years).

And I see you're taking Cytomel too... I assume this means you're hypothyroid? I am, too. sucky combo with the depression, can definitely cause turd.

Also, you did mention in another post that you live in South Carolina. That probably doesn't help, either.

hollywood--

I got you confused with another CBer who had a thread about Effexor+trazodone for a similar condition. That's why I thought Remeron had made you obese! my apologies.

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Hmm...I have treatment resistant Bipolar II, mostly depression. Tried over 15 medications, hospitalized four times in the last five years. Over 40 ECT treatments in the last five years, a VNS stimulator, lots of psychotherapy. Lost my job, my house, and sent my 15 year old sons to live with their dad. Even gave my dog away. On disability. THIS is treatment resistant depression. I'm feeling better now.

Talk about having to deal with a "turd". I genuinely feel sorry for you. I'm not going to suggest the cocktails I mentioned above, since you've probably tried them already. I won't lecture you on the med-go-round, since you've been on it longer than I have (3 years).

And I see you're taking Cytomel too... I assume this means you're hypothyroid? I am, too. sucky combo with the depression, can definitely cause turd.

Also, you did mention in another post that you live in South Carolina. That probably doesn't help, either.

hollywood--

I got you confused with another CBer who had a thread about Effexor+trazodone for a similar condition. That's why I thought Remeron had made you obese! my apologies.

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Yes, I have hypothyroidism, under control. No need to feel sorry for me. I'm learning to manage this illness and find joy in small ways when I can. My depression is not as deep any more. I'm amazed at what people will do to to help me. Yes, I lost every thing but my faith. And I've learned that my faith works to sustain through anything. I always felt that way during my deepest darkest pain. But who do I find myself crying out to when everyone else has done what they can do? A higher power. And I have developed more of a trust in it. That's not a bad thing. I hope I haven't offended you with spirituality stuff. I'm sorry that you have to go through all of these medication changes. Depression is hell. There is hope. You won't feel this way forever. You can learn to manage this illess. Hang on for dear life. I'll be looking for your posts.

Why is S.C. bad for depression

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No sweat Herrfous.

I don't want to give the wrong impression--*I* don't think I have treatment resistant depression by a long shot. I agree with everyone's definitions given here. Sometimes I wonder if my pdoc is making things more complicated than they need to be, really.

I think Lamictal might be good for me because I seriously think I am a rapid cycling unipolar.

Sunshine, I'm so glad that you said you are feeling better, after everything you have had to go through. Severe depression truly is hell on earth.

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No sweat Herrfous.

I don't want to give the wrong impression--*I* don't think I have treatment resistant depression by a long shot. I agree with everyone's definitions given here. Sometimes I wonder if my pdoc is making things more complicated than they need to be, really.

I think Lamictal might be good for me because I seriously think I am a rapid cycling unipolar.

Sunshine, I'm so glad that you said you are feeling better, after everything you have had to go through. Severe depression truly is hell on earth.

You may be right.

I may be crazy.

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Yes, I have hypothyroidism, under control. No need to feel sorry for me. I'm learning to manage this illness and find joy in small ways when I can. My depression is not as deep any more. I'm amazed at what people will do to to help me. Yes, I lost every thing but my faith. And I've learned that my faith works to sustain through anything. I always felt that way during my deepest darkest pain. But who do I find myself crying out to when everyone else has done what they can do? A higher power. And I have developed more of a trust in it. That's not a bad thing. I hope I haven't offended you with spirituality stuff. I'm sorry that you have to go through all of these medication changes. Depression is hell. There is hope. You won't feel this way forever. You can learn to manage this illess. Hang on for dear life. I'll be looking for your posts.

Why is S.C. bad for depression

I think faith does have a major component in dealing with MI. I don't think I'd have been able to maintain myself on this Earth had I not believed I had some purpose, be it trivial or grand, in life. I assume you read/post on the spirituality section of CB. Things get quite interesting there.

And thank you for your concern. I don't classify my own depression as "turd", since it's mostly in remission now, save for the fact that my ass is in debt and will be for at least 3 years. Well that and the brain rotting away thing, have to stop that before it gets in the way of doing a Master's degree.

I have empirically determined that SC is bad for depression, since I live across the river and have become more depressed since moving that close to SC. Well that and quite a few CBers are from SC (or my town across the river).

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  • 1 month later...

Ahoy. I was just passing by, as it were, and thought I'd mention that my double-depression has been labelled treatment-resistant (or "refractive" if you want a to use a $10 word).

It does seem a little precipitous to go from a single SSRI to "treatment-resistant", but I don't think you necessarily have to have tried everything including the tricyclics to merit "resistant". I would imagine that if the average depressive gets a little oomph out of one or other of the SSRIs, then the pdoc may be encouraged that treatment may not be a complicated affair. It's when soaking in SSRIs leaves you utterly flat that you know things are going to get complicated. (For some reason I just had an image of Madge the Manicurist with her hands in a bowl of serotonin - "Serotonin? I'm soaking in it!"

I didn't really do the med-go-round all that much, though; Prozac > Wellbutrin > Prozac + Wellbutrin > Effexor > off Effexor {primal scream} > Lexapro (flopped miserably) > on Effexor at a Norepinephrine dose, which makes headway but doesn't smack down the Dysthymia > Effexor + Adderall = DING! At last a hint of normalcy. Ok, it's Bizarro-World normalcy, but still.

My condition is still there; I can feel it, lurking just below the surface, but once I found the right combo, it was like realizing that the purpose of treading water is to keep one's head above the surface. I've been bobbing about for a little while now with my nostrils barely out of the water, but hey, at least it's air. The point is, "treatment-resistant" does not mean "treatment-proof".

Ah, well. Away we go. The outer world awaits.

Cerberus

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Anyway, it's just kind of strange to me that he thinks this kind of aggressive treatment is warranted. I know he is just trying to get me feeling better, and I'm ok with it as long as my body can handle it, but still...a little weird given my really limited prior med history.

Have any of you been labeled as "treatment-resistant"? What definition does your pdoc use? Just curious.

I'm still waiting to get in with a pdoc for my depression and it's ability to poop out meds (the wait here is 6months if I want the ONE person within 2 hours that's covered my my insurance--bleh, long story and not the point) but I do agree that your doc slapping that label on you after so few tries is a bit odd and jumping the gun. Especially if a SSRI worked for you at all- there are so many different meds that work on those same chemicals that I'm pretty surprised he didn't try messing around with a few more SSRIs.

But ANYWAY, the point is that there is no real solid definition that all doctors use to label someone as a treatment resistant depressive (also called refractory depression IIRC) and therefore one doctor might stick that label right on ya, while another would try each class of ADs, several combos of classes, etc. before using that label. I wouldn't worry so much about the specific label, I would talk to your doctor about *why* he skipped over trying other SSRIs and the more conventional treatments and prescribed what he did. Be totally honest if you feel like it might be overkill and you want to maybe try something simpler-- there's no point in loading your poor body up with tons of different drugs if one can work, you know?

Hope that I made some sense!

Goodluck, and try to be as honest as possible with your doctor, and ask a LOT of questions!

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