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Treatment Resistant or Misdiagnosed?

Treatment-resistant depression (TRD) is a hot topic for psychiatrists right now. With the approval of SpravatoTM earlier this year, there are now three treatments for TRD including electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS).

Dr. Joshua Morris

As a mood-disorder specialist and purveyor of ECT, I am frequently approached to consult on a patient with TRD. Unfortunately, I often find that the patient is not a candidate for ECT, either because they were misdiagnosed or they haven’t actually had adequate trials of medications. Feeling sad or depressed can be due to depression but it can also be caused by many other conditions, especially generalized anxiety disorder or personality disorders. As a patient, it’s very important to be educated about your condition and to be discerning when it comes to receiving advice from your physician. After all, you are paying him or her to give you advice. Just as it wouldn’t make sense to completely ignore the advice, you should also not blindly accept it. Physicians will not be upset if you are skeptical as long as you have an open mind. Most of us encourage curious patients and enjoy teaching anyone who shows interest. To that end, I encourage patients to be skeptical and to participate actively in treatment decisions.

Regarding accurate diagnoses, it’s critical to exclude other possible explanations for your symptoms. I often find that patients have some symptoms of depression but not enough to meet criteria for major depressive disorder. Therefore, if we went ahead with one of the treatments mentioned above, we couldn’t predict the likelihood that it will be helpful. Even if it is helpful, it’s more likely due to a placebo effect. I like to go through the criteria with my patients to help them understand why I’m making a particular diagnosis. I think patients should ask why they are given a certain diagnosis and maybe even look up the criteria for themselves. However, I do urge a word of caution. It can be difficult, if not impossible, for a person to be aware of signs of psychiatric illness in themselves so it can be helpful to ask trusted others what they think.

When it comes to medications, I find that either the patient or the physician is too quick to make changes or give up on a medicine. For many medications in psychiatry, the desired effects are delayed anywhere from one to eight weeks. If your condition is mild and doesn’t interfere significantly with your life, a reasonable strategy would be to try a certain dose of medicine for the necessary period of time before increasing the dose. In that case, it’s important to maximize the dose based on the highest dose tolerated or the maximum recommended dose. Notably, the side effects of medications usually come on much quicker. Therefore, for more severe cases, I usually recommend an alternative strategy of maximizing the dose as quickly as the patient can tolerate before waiting the necessary amount of time to see if the medicine is helpful. Either way, we can’t say that a medicine doesn’t work unless you can’t tolerate it or you’ve tried a high enough dose for long enough. Finally, there are many conditions for which therapy is an important part of treatment or the only thing that is likely to help.

In summary, when you work with a physician or an expert in any field, it’s important to be a savvy consumer. Find someone you trust and take their advice seriously but don’t be afraid to ask questions or seek a second opinion if you have concerns.

May is Mental Health Awareness Month! During the month of May, we join organizations across the country to raise awareness of mental health. Together, we fight stigma, educate, advocate, and provide support for the millions of Americans who face the reality of living with a mental illness.

Eastside Behavioral Health Associates
2160 Fountain Drive, Suite 100
Snellville, GA 30078