This case is a composite of several different patients and is for illustrative purposes only. The patient's name has been changed to protect anonymity.
Blair is a 17 year old that was seen in my office Mar 2017 after a psychiatric hospitalization due to a failed suicide attempt. He had 2 previous psychiatric hospitalizations in Dec 2016 after similar failed suicide attempts. He was also in an Intensive Out-Patient program 1 1/2 years ago for management of his persistent depression. He was referred to me after not responding to treatment by his previous psychiatrist.
Psychopharmacogenomic testing (AKA "Genomic Testing") is a new tool that has been available to clinicians during the last few years. Armed with patient genetic information, clinicians can more quickly identify effective therapies, thus limiting the prolonged suffering and economic burden place upon many patients with chronic illness. This includes patients with treatment resistant depression, bipolar disorder, anxiety and attention deficit disorder (ADD).
Patients who are treated for depression improve with treatment. However, there is a subset of them that are less depressed but still not able to function as well as they are expected. They feel better but are not well.
Wellness is a concept that is often times elusive. In my experience, this obstacle can most often be due to an anxiety disorder that has not been treated or has not been diagnosed.
1. Major Depressive Disorder: There are various depression scales that are available that have screening questions for depression. These include HAM-D, MADRS, Beck Depression Inventory, Zung, etc.
However, I ask my screening questions in a way that is more conversational so as to continue a dialogue rather than a formal Q&A type of interview.
Key questions should query about level of energy/motivation, irritability or tearfulness, sleep and appetite changes, social withdrawal towards friends and family, feelings of hopelessness and worthlessness, suicidal thoughts or suicide attempts.
Patients with Treatment Resistant Depression (TRD) have more than one disease state at a time. TRD is defined as a depression that has not improved with 3 or more psychotropic medications including antidepressants, mood stabilizers, stimulants or second generation antipsychotics.
This is probably makes up 50% of the treatment process. The patient has to WANT to change for the better. Change takes time, effort, commitment and patience. These attributes will be tested during the sometimes long and arduous process of treatment.
I always refer my patients to a good psychotherapist to help with this process. A good therapist will be able to help with non-medications issues related to the patients psychological functioning. There might be issues that get in the way especially with relationships with others and themselves. Some common issues deal with accepting the illness, accepting treatment with medications, control issues, maladaptive behaviors, to name a few.
Dr Jesalva is a psychiatrist. He is in private practice in Thousand Oaks, CA since 1989. He successfully treats very challenging patients with varying co-occurring disorders with medications.