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thinking of making a change

Posted by Melusine on October 28, 2017, at 10:13:40

Hi everybody. An intro....

I've been suffering from treatment-resistant depression for years. (Type is melancholic/ "typical," although AFAIK this doesn't help much when it comes to treatment.) A few years ago (well, < 10, anyhow), I gave up on trying to recover more fully and settled for the best tx combo I'd been able to find. This was after trying just about everything available at the time: psych meds (even some admittedly not all clones, as well as a lot of meds more typically used for anxiety, psychotic d/o's, bipolar, etc.), talk therapy (various sorts; CBT was the only one I found particularly useful, and even there, I think I probably could have gotten equal benefit from reading the material in one or more self-help books), and other types of tx's (ECT more about this below was the only one that helped at all; the evidence for some of these is really poor but they're permitted because of an apparent lack of danger). I also considered the possibility of a wrong or incomplete diagnosis, since after all there isn't an objective test for any of this stuff (thus I tried meds that weren't used often, if at all, for depression, usually on the grounds of "augmentation," which was a fairly new idea and gaining in popularity at the time). I'd reached partial remission, and full relapses have been rare since I added maintenance ECT to my Secret Stew. I prefer not to specify which meds I'm taking, as it's a novel combination and I'd rather keep my identity private. My current psych med kit includes one monoaminergic and one other type of AD, a "z-drug" for sleep, and a benzo for occasional anxiety and/or psychomotor agitation (jitters mostly pacing & suchlike). Not that many meds when you compare it to the number that a lot of people here are taking.

At the hospital where I get the ECTs, they use a variation on bifrontal electrode placement in place of bitemporal (the old-style bilateral placement, which almost invariably causes serious memory problems). It causes relatively mild cognitive side fx; while it's not a huge problem (I wouldn't be the first to suggest that perhaps the amnestic effects of ECT aren't entirely independent of its benefits), I would still d/c the treatments if I thought I could get away with it. I have tried stopping a few times (3, I noted, my memory isn't quite what it once was), but I invariably suffered a relapse within a few months. The last time I tried it was a few years ago (this was also my most recent relapse).

While the present combination of ECT and meds I'm using has kept the depression more or less under control, I've never achieved 100% remission. As many people here are doubtless aware, mood episodes tend to get more frequent with each recurrence. I think they also get more severe. (Though I'm only entirely certain of the former, both are definitely consistent with my experience.)
Every episode of depression I've experienced included early-morning insomnia (sometimes I've had sleep-onset insomnia also, but that might not have been related to the depression it's hard to figure out exactly where to draw the line between depression and anxiety, for example), and over the years the insomnia stopped going away even when I wasn't depressed. By this time it's chronic. While my mood has been generally okay, anhedonia and lack of motivation are still problems, though mild compared to full-blown depression. I still haven't been able to work or return to school. (I was at university, working on a graduate degree, when I had to drop out because of depression.) I've spent most of the intervening years helping my mother take care of my father, who died recently; while I'm glad I was able to be with him during his final years, it hasn't exactly been a fulfilling life.

I'm not sure what in particular has led me to this (rather abrupt) reconsideration, although I hope I've made it clear that I have ample reasons for wanting at least to improve my condition, even if I'm still not able to overcome it sufficiently to live a normal life. It doesn't look all that promising...there aren't many new tx's available that have shown any particular promise in TRD, and most of the "new" ADs are pretty much just more of the same monoaminergic clones, not all that different from the SSRIs, mixed reuptake inhibitors like duloxetine and venlafaxine (although by itself isn't much of a NRI, its metabolite desvenlafaxine contributes significantly), and reputake-inihibitors that are also agonists and/or antagonists at various (mostly 5-HT) receptor subtypes (nefazodone, mirtazapine, etc.).

I tried taking desipramine a couple of times. The first time, which was a long time ago, side fx were a problem and I ended up switching back to the AD (a nontricyclic) I'm taking now, but it did work about equally well. The last time I tried it in was in combination with a MAOI; the result was an unexpected case of serotonin syndrome. I'm definitely not a CYP2D6 poor (or ultrarapid) metaboliser: I actually had a TCA serum level once while taking nortriptyline, and it was in the expected range. I still wonder whether there might have been some unexpected interaction with one or more of my other meds (possibly due to competitive CYP450 enzyme inhibition). Some TCAs also are antagonists at some of the 5-HT receptors, and this is the only explanation I can come up with. Anyway, whatever the cause, that was the end of that.

At my last appointment, I told my pdoc (with some hesitation) that I'd been feeling like I ought to try and deal with the symptoms still troubling me. As I mentioned in another thread, he suggested ketamine. Considering how weird a combo I'm already on I've found pdocs often reluctant and occasionally even refusing to prescribe some of the stuff I'm taking despite the fact that I'd been on it for years already and could give them contact info for multiple previous pdocs who could vouch for the fact that I hadn't abused any of my meds and have no history of drug abuse. I thus have been worried that adding yet another controlled substance will only cause me more trouble of this sort.

(For clarification: ketamine is in Schedule III under the US Controlled Substances Act, the same category as intermediate-acting barbiturates, anabolic steroids, and buprenorphine, as well as a couple of otherwise-illegal drugs like Marinol (THC...ignoring, of course, the vast amount of confusion about the legal status of cannabis in states where it's been legalised; it's still officially illegal on the federal level) and Xyrem (GHB). For comparison, Schedule I is things that are completely illegal, II includes most opioids (other than heroin (diacetylmorphine), which is C-I) like morphine, fentanyl, methadone, oxycodone, codeine, etc. (some formulations combined with APAP used to be C-III but were moved up), which is Schedule I), stimulants like amphetamine (including Dexedrine and Adderall and pharmacologically-similar analogs like methamphetamine), Ritalin, cocaine, short-acting barbiturates, PCP, etc. Schedule IV includes benzos, z-drugs, some weak opioids like Ultram, and long-acting barbs. As you can see, the whole thing's pretty arbitrary.)

Anyhow, I was wondering if anyone here had any alternative ideas that I might not have tried yet. (I'm not entirely opposed to monoaminergics (might even give desipramine another try) though some of my remarks here may sound like it.)

(Not my real name. Melusine was a mythological creature, possibly a demigoddess or half-fay, sort of like a mermaid; she was generally described as half-human/half serpent. Several houses of European nobility claim to be descended from her including the houses of Luxembourg, Poitou, and Anjou [and from the latter, the royal house of England].)




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