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Treatment-Resistant Depression


Treatment-Resistant Depression

October 24, 2022

When treating depression, physicians often prescribe a first-line anti-depressant (e.g., Zoloft, Prozac, and Lexapro). While these treatments work for many, a significant portion find that their symptoms remain even after trying several antidepressants. Known as treatment-resistant depression (TRD), this condition affects around 30 percent of adults with major depressive disorder (MDD).

 

Despite its prevalence, many are unaware of treatment-resistant depression, how to determine if they might have it, or what to do about it. 

 

Explore answers to these questions and more below.

When is Depression Treatment Resistant?

Treatment-resistant depression is generally defined as a lack of response to a few adequate trials of antidepressants. However, this leaves several questions open, including:

 

  • What counts as a lack of response?
  • What is an adequate trial?
  • How many antidepressants must a patient have tried?

It’s important to note that there are no universal answers to these questions. Instead of settling them, try answering the following questions:

 

  • Have your treatments failed to make you feel good?
  • Do you still not feel like your old self?
  • Have the side effects been difficult to manage?

Answering yes to any of these questions means you’re not getting the help you need, and it’s time to talk to your physician, who can decide the next best course of action. 

Risk Factors for Treatment-Resistant Depression

Though researchers are still uncovering all traits that can increase the chances of having or developing TRD, we know several factors are associated with the condition. In particular, depression is more likely to be treatment-resistant:

 

  • If it began at an early age
  • The longer one has had depression
  • The more frequent or longer lasting one’s depressive episodes are
  • When there are ongoing stressors
  • If one has other physical or mental health conditions

What to Do About Treatment-Resistant Depression

Treatment-resistant depression is treatable. Below are steps you and your physician can take to alleviate your depressive symptoms that haven’t responded to the first few treatments.

 

  • Confirm your diagnosis: Depression that co-occurs with or is caused by other mental health conditions may require a different treatment protocol. As a result, your physician should confirm your diagnosis if your depression isn’t improving in response to treatment.

 

  • Add on talk therapy: Medications often work best when combined with some form of talk therapy. If you find your depression hasn’t responded adequately to your antidepressants, adding on therapy can give them a boost and help alleviate symptoms.  

 

  • Change your medications: Just because a few medicines haven’t worked doesn’t mean none will. Newer anti-depressants (e.g., Spravato and Auvelity) that act on different neurotransmitters than first-line treatments can provide relief even when the standard solutions haven’t worked.

 

  • Try a non-medication-based intervention: While oral antidepressants are the most common medical treatment for depression, other options exist. For example, transcranial magnetic stimulation (TMS) is a non-invasive procedure where magnetic pulses are used to modulate activity in parts of the brain associated with mood regulation and is FDA approved for treatment-resistant depression.

How We Treat TRD at Heading Health

At Heading, we offer a comprehensive set of solutions to tackle TRD from every angle and provide rapid and sustained relief. We work hard to ensure that cost is not a barrier to accessing the interventions you need. We work with most insurance plans, from United Healthcare to Medicare to Blue Cross Blue Shield, and can provide coverage for all of our services, including ketamine, Spravato, and TMS, for most patients with TRD. Click here for a complete list of participating providers and to schedule a consultation to see whether our solutions are right for you. 

 

 

 

If you need to see a mental health professional or could use help deciding which service is right for you, please call us at 805-204-2502 or fill out an appointment request here. We have a wide variety of providers, including therapists, psychiatrists, nurse practitioners, and nutritional therapists, who can see you in as little as one day via teletherapy.  

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What Does Spravato Feel Like? A Patient’s Perspective 


What's Does Spravato Feel Like? A Patient's Perspective

October 3, 2022

This post was written by a member of our content team who is currently receiving treatment using Spravato in Michigan. In the interest of transparency, he is not a patient of Heading. However, his treatment program and the experiences detailed in this post are very similar to those of patients at Heading.

 

I have suffered from anxiety and depression for most of my life. Treatment began at age 12 when I was diagnosed with generalized anxiety and obsessive-compulsive disorder (OCD). While the initial treatments helped to some degree, many symptoms remained, and the side effects of the drugs I took became intolerable. 

 

Over the next 17 years, I switched from one oral antidepressant to the next, desperately trying to find something that addressed my symptoms without causing side effects that were worse than what I was trying to treat. Eventually, my psychiatrist recommended a drug called Spravato (esketamine nasal spray), a rapid-acting drug used for treatment-resistant depression. He told me that Spravato works differently than traditional antidepressants by increasing levels of glutamate and brain-derived neurotrophic factor (BDNF). These two changes have been associated with improvements in depression and anxiety. Knowing this, I felt hopeful that I might get the benefits I was looking for without the drawbacks I was trying to avoid.

 

Though I was excited about trying out the new intervention, I grew increasingly anxious as I awaited my first treatment session. Both esketamine (the active ingredient in Spravato) and its more famous cousin, ketamine, are psychoactive, meaning they can alter one’s normal state of consciousness, affecting one’s thoughts, feelings, and perceptions. 

 

Before trying Spravato, I had very little experience with psychoactive drugs and none with anything that might be considered a psychedelic. As a result, I had no idea what to expect. To make matters worse, I felt that I wouldn’t react well to the experiences that Spravato might bring about because I suffered from severe anxiety. I went into my appointment blind to what I was about to experience. Though my fears were unwarranted, I would have benefited greatly from a clear and honest description of what was to come.  

 

My Experience with Spravato

Below I describe to the best of my ability what I typically feel during a Spravato treatment session. Though some of these experiences may generalize, it’s important to remember that everyone’s brain is unique and may react differently to Spravato.

 

Dissociation

One of the more talked about effects of Spravato is its ability to cause dissociation. Though it is described differently by different people, the effect is generally characterized as a temporary feeling of disconnection from one’s thoughts and feelings.

 

I like to describe my personal experiences with dissociation as akin to the sensation one gets when looking at their avatar through a virtual reality headset. Everything is in the location it’s supposed to be and moves when it should, but you don’t identify with your avatar. Its movements don’t feel like your movements. Its body doesn’t feel like your body.

 

The feeling of separation from my thoughts is harder to describe. The best I can say is that it feels like I am “viewing” my thoughts rather than “thinking” them. They simply pass by, unauthored by me.

 

Feeling of Relaxation

Despite having unusual sensations like the feeling of dissociation, I often experience a wave of relaxation as my concerns and worries drift away. My thoughts quiet down, and former troubles begin to feel like they don’t matter as much.

 

Feelings of Stress and Anxiety

Though Spravato can be pleasurable, it can also be unpleasant and stressful. I believe this is at least partially the result of the following two factors.

 

First, while under the effects of Spravato, my mind tends to focus on unpleasant thoughts at the core of many of my worries (more on this below). Though these thoughts are easier to entertain at the time, they can still be challenging to confront.

 

Second, aside from its psychological or psychoactive effects, Spravato causes physical sensations that tend to be more unpleasant. For example, I often get dizzy and feel like I am slowly spinning in my chair. As a result, I feel nauseous. When these sensations become too intense, the overall experience can become quite stressful. Fortunately, my doctor prescribed an antiemetic (i.e., an anti-nausea drug), so these sensations have become less frequent and more tolerable.

 

Increased Empathy

The state that Spravato puts me in makes it easier for me to put myself in other peoples’ shoes. Often, I will spend time thinking about past arguments or disagreements. While doing so, I have an easier time understanding where the other person was coming from and why their reactions and feelings were appropriate. More generally, I tend to have a stronger concern for the well-being of others.  

 

Enhanced Ability to Confront Unpleasant Thoughts

Through my Spravato experiences, I have realized that at the heart of many of my daily fears are more general worries that I have trouble recognizing or confronting. While under the effects of Spravato, my attention is almost unavoidably directed toward these fundamental concerns

 

Here’s a personal example to shed light on how this works. Among the many things I worry about, work is often at the top of the list. I worry while working on assignments, submitting them, waiting for feedback, etc. Though I had spent so much energy feeling anxious about this, I never looked at the underlying concern or belief that connected all these more specific worries. During one Spravato treatment, I realized that I had deep concerns about my intellectual abilities and that I viewed each work assignment as a potential instance where my real lack of capability would be revealed.

 

Though the fear remains, knowing it exists and is responsible for so many other specific worries has made it easier to deal with.

  

Visual Distortions

Around 10 minutes into each treatment, I start to notice some visual effects. First, my vision becomes fuzzy, and I have trouble refocusing each time I move my eyes. Over the next few minutes, this effect increases in intensity until everything looks as though it is shaking for a few seconds after I shift from looking at one spot to another.

 

Aside from becoming fuzzier and shakier, my vision tends to change in a different way. Specifically, objects appear to be slowly expanding and contracting as if they are breathing. Often, I’ll try to match my breath to the rate at which the things are “breathing.” It’s pretty relaxing.

 

When I close my eyes, I notice a further visual effect. As I keep them shut, I see faint geometric patterns. This is especially noticeable when my eyes are almost but not completely closed, which happens to me somewhat frequently when dozing off under Spravato. My guess is that my brain is doing its best to interpret the unusual visual stimuli it is getting, and the result is that I have some minor closed-eye visuals.

 

Post-Treatment Effects

Though many of the effects subside by the end of the two-hour treatment, some remain for several hours. I tend to feel tired, off-balance, and a bit groggy. These effects slowly dissipate as the day goes on but do not linger into the next day.

 

Concluding Thoughts

From enhanced empathy to feelings of dissociation, Spravato experiences can feel intense or overwhelming when you don’t know what to expect. After I learned first-hand what the experience feels like, my Spravato sessions became much more relaxing and pleasant. Hopefully, my descriptions will help other anxious patients get there more quickly.

 

Stay tuned for part two of this blog, where I describe the long-term effects of Spravato on my depression and anxiety.

 

If you feel you need to see a mental health professional or could use help deciding which service is right for you, please give us a call at 805-204-2502 or fill out an appointment request here. We have a wide variety of providers, including therapists, psychiatrists, nurse practitioners, and nutritional therapists who can see you in as little as one day via teletherapy.  

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Want to find out if Heading is right for you? 

Complete our consultation form and an intake specialist will get in touch.


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Study Finds Ketamine Provides Rapid Relief from Severe Suicidal Ideation​


Study Finds Ketamine Provides Rapid Relief from Severe Suicidal Ideation

September 20, 2022

Each year, around 800,000 people die from suicide, and nearly 20 times that number attempt it. 

 

Though the causes of suicide and suicide attempts are varied, it is often preceded by suicidal ideation (i.e., contemplations, wishes, and preoccupations with death and suicide). As a result, researchers have increasingly been searching for compounds that treat these thoughts and feelings. 

 

Ketamine has stood out as a promising candidate, with several studies indicating that it is highly effective against suicidal ideation. While these results are encouraging, they generally have not focused on patients experiencing more severe suicidal ideation (SI) or in the middle of a suicidal crisis. Additionally, as far as outcomes go, many studies have measured the number of “treatment responders” (i.e., individuals who experience at least a 50 percent reduction in symptom severity) as opposed to the amount who experience remission (i.e., a complete absence of suicidal ideas).  

 

To fill in these gaps, a team of researchers led by Dr. Mocrane Abbar conducted a double-blind placebo study to assess the effects of ketamine on cases of severe SI. Due to its double-blind placebo-controlled structure, half of the subjects were given an inactive ingredient not known to improve SI. Additionally, neither the subjects nor the experimenters knew whether ketamine or the placebo was given. 

Key Findings

Below are some of the key findings from this study.

 

 

The Majority of Patients Achieved Full Remission

Sixty-three percent of the severely depressed subjects achieved complete remission of their suicidal ideation after just three days and two ketamine infusions.

 

It Worked Rapidly

SI is an urgent condition warranting an immediate and swift response. As such, it’s vital that ketamine not only works for many patients but also exerts its effects quickly and robustly.

 

As the graph above shows, many patients achieved remission almost immediately. Specifically, 43.8 percent of participants suffering from severe suicidal ideation achieved remission of their symptoms only two hours after their first infusion.

 

 

The Effect was Persistent

Immediate and robust relief of SI is a significant result on its own. However, this finding may have a limited impact if SI promptly returns. Fortunately, the researchers found that the effect lasted six weeks for nearly 70 percent of the patients.

While far from permanent, the six-week reprieve many patients experienced is promising for several reasons. For one thing, given that suicidal ideation is strongly associated with suicide attempts, these subjects may be far less likely to attempt suicide within those six weeks. Second, repeated infusions may lengthen this period of relief even further. Additionally, patients who have yet to create a holistic system of support to supplement their pharmacological treatments with other forms of therapy may find they have more energy to do this while the ketamine is lifting the heavy mental burden of severe SI.

 

 

The Effect was Strongest for Those Suffering from Bipolar Disorder

The research team found that ketamine’s therapeutic effect on SI generally depended on the mental condition the patient was suffering from.  More specifically, they found that ketamine infusions had the strongest impact on SI in patients who have bipolar disorder.

 

Among individuals suffering from depression, the effect was more moderate, with 42 percent of subjects experiencing a remission of their SI.  To shed light on the result, the researchers note that “one study of treatment-resistant depression suggests that repeated doses of ketamine might be necessary for some patients to achieve remission of severe suicidal ideas.” In other words, it may be that this group would have experienced a more significant improvement in their SI symptoms had they undergone more ketamine infusions.  Future studies will need to verify whether this is true.

 

 

It Alleviated “Mental Pain”

In addition to compiling more robust, reliable evidence that ketamine is a good treatment for severe SI, the research team collected data that may shed light on why it is so effective. In particular, they measured patients’ levels of “mental pain” and looked for correlations with remission levels.

 

They found that patients’ self-reported mental or psychological pain was strongly correlated with the severity of their SI and that the ketamine infusions had the most substantial positive effect on their SI when they alleviated psychological pain. This suggests that ketamine’s impact on SI is, at least partly, the result of its ability to relieve psychological pain.

Conclusion

Research continues to verify ketamine’s therapeutic effect on SI. This study provides some of the strongest evidence to date, suggesting that ketamine can provide rapid relief in cases of suicidal crises. It also sheds light on why ketamine has this effect and indicates that the degree to which it is helpful may depend on the individual’s particular mental health condition. 

 

If you are experiencing symptoms of SI, please contact the Suicide Crisis and Prevention Lifeline at 988

 

If you feel you need to see a mental health professional or could use help deciding which service is right for you, please give us a call at 805-204-2502 or fill out an appointment request here. We have a wide variety of providers, including therapists, psychiatrists, nurse practitioners, and nutritional therapists who can see you in as little as one day via teletherapy.  

Take the first step

Want to find out if Heading is right for you? 

Complete our consultation form and an intake specialist will get in touch.


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