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Special Issues - Severe Depressive Disorder and Dual Diagnosis

Rashmi Nemade, Ph.D., edited by Kathryn Patricelli, MA

Severe, treatment-resistant depression

Long-term depressive symptoms that do not respond to treatment usually lead to greater levels of disability, a greater likelihood of the reappearance of major depressive episodes in the future, and a poorer prognosis (expectation) with regard to work and social performance. Treatment is complicated with trying different antidepressants and other therapies.  About 50% of people with major depressive disorder do not recover completely.  Up to 80% of patients who needed more than one course of treatment found themselves depressed again within a year.

Remember that depression therapies do not work instantly. They require several weeks to several months to take effect. An individual must wait for at least six to eight weeks before deciding that they are not responding to a particular medication or type of psychotherapy. Multiple medications, different types of psychotherapy or different therapists should be tested before a person decides that he or she has treatment-resistant depression.

The first step for people who are dealing with treatment-resistant depression is to review their diagnosis. Repeating initial diagnostic tests and doing new ones may uncover other factors (such as a thyroid problem, etc.) that the original clinician may have missed initially.

When all diagnostic work has been checked, it is appropriate to work try additional medication combinations or to move on to non-medication treatment options.

Treatment-resistant depression is often treated with:

  • lithium
  • antipsychotic medications
  • electroconvulsive therapy (which has the highest rate of response of any form of antidepressant treatment),
  • vagus nerve stimulation (VNS)
  • rTMS (Repetitive Transcranial Magnetic Stimulation).

Electroconvulsive therapy and similar forms of therapy are typically considered last attempts. They should be tried only after all options for treatment have been exhausted.

Dual diagnosis or co-occurring disorders (COD)

The concept of dual diagnosis can be used broadly. For example, depression and substance abuse or a person who has a milder mental illness and a drug dependency. This could be both panic disorder or generalized anxiety disorder and also being dependent on cocaine. People with co-occurring disorders have increased rates of relapse, hospitalization, homelessness, and HIV and Hepatitis infections compared to those with either mental or substance use disorders alone.

These problems usually start because many people with depression try to make themselves feel better by "self-medicating."  This means that they drink alcohol or take drugs to try to feel better.

Unfortunately, use of these substances only makes the problem worse by placing the person with depression at risk for developing substance addictions in addition to their depression.

Research suggests that people with psychiatric problems are much more at risk for addiction than the general population. In addition, people who abuse alcohol, drugs or other substances have an increased risk of major depressive disorder. People with depression who have substance addictions are more likely to need hospitalization, more likely to attempt suicide, and less likely to succeed in treatment than are people with depression who are not addicted. As a result, patients who have both depression and substance abuse diagnoses are often treated separately in inpatient settings and group therapy sessions from those patients with depression only.

Patients with dual diagnosis are harder to treat than patients who experience only one disorder at a time. The basic rule followed by most dual disorder treatment programs is that patients need to become sober before real treatment of their depression can occur. The first step for a patient with co-occurring disorders is detox during which the body is allowed to cleanse itself of alcohol and/or drugs. Detox should be medically monitored as complications such as infections and/or lung, kidney, or liver problems can happen. Some drugs are safer to detox from than others. Specifically, it is never safe to detox from alcohol without medical attention during the process. The amount of time necessary for detox varies, depending on the particular addictive substance, the frequency of use, and the quantity consumed.

For those people whose addiction is severe, inpatient treatment may be necessary. Individuals with less severe drug or alcohol addictions may benefit from an outpatient dual diagnosis treatment program. However, this outpatient treatment is only successful for people who are self-motivated and willing to take active steps towards improving themselves and working towards recovery.

Within specialty inpatient or partial hospital dual disorder treatment programs, detoxified patients are offered simultaneous and intensive therapies designed to help them maintain sobriety and to address their psychiatric issues, including depression. Medications are given and monitored. Relapse prevention techniques are taught, and group therapies are offered. Patients are screened for substance use on a continuing basis. Sometimes, they are also encouraged to participate in various twelve-step programs such as Alcoholics Anonymous, Narcotics Anonymous, Marijuana Anonymous or Cocaine Anonymous. Patients who manage to maintain sobriety for a while may be offered more specialized psychotherapy for their depression or other psychiatric condition.

The transition from hospital or partial hospital care to outpatient care is particularly critical for dual diagnosis patients. After completing a dual diagnosis program, patients are more likely to enjoy continued success when they can be transitioned into aftercare programs and sober housing in order to prevent relapse.

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