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Tag: treatment-resistant depression

  • Go to a Pool

    Go to a Pool

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    In this summer of heat domes and record-breaking global temperatures, finding a place to cool off is more important than ever. You can go to a movie or a museum—if you want to buy a ticket. You can head to an air-conditioned bar—if you don’t have kids who also need to escape the heat. Or you can just stay at home and blast your own air conditioner—a rather lonely prospect, if you ask me.

    But there’s a better way to cool down, no air-conditioning or entrance fee required: America’s hundreds of thousands of public pools. Cool water, fresh air, exercise, babies, teenagers, seniors: They’re all at the pool. In a time of increasing heat and social isolation, public pools are a blessing.

    Where I live, in Manhattan, we have several outdoor pools smack in the middle of the sultry cement jungle. For that, my neighbors and I can thank, among others, Robert Moses, the urban planner who was instrumental in creating New York City’s public pools. Moses was a staunch advocate for public swimming. “It is no exaggeration to say that the health, happiness, efficiency, and orderliness of a large number of the city’s residents, especially in the summer months, are tremendously affected by the presence or absence of adequate bathing facilities,” he wrote in 1934.

    Swimming does, in fact, have important benefits for physical and mental health. Perhaps most crucial this summer: Immersing yourself in cold water can quickly lower your body temperature on a hot day. Swimming is fantastic aerobic exercise, and it’s easier on the joints than many other activities that raise your heart rate. Aerobic activity reduces stress, and swimming in particular has been shown to improve mood. In one preliminary study, swimming in the cold ocean reduced feelings of depression up to 10 times as much as watching from the beach did. In a separate case study, a woman with treatment-resistant depression experienced a significant improvement in her symptoms after swimming in open water once a week.

    I’ve loved swimming since I was a young child, when my father taught me, and even now, whenever I’m in a bad mood, I reflexively take myself to the water. I’ve always thought the mood-boosting effects of swimming were solely the product of the exercise and the resulting flood of endorphins in my brain—that I might get the same effect from, say, a hard weight-lifting session or a long run. But the thing is, the studies that find that swimming lifts your mood tend to involve swimming with other people. Perhaps the social contact is part of the magic too.

    Early in the pandemic, when life ground to a halt, the indoor pool where I swim in the offseason had very strict rules. You had to reserve a time, and there were never more than two people in a lane. It should have been a swimmer’s dream: no crowd and a guaranteed lane. I swam just as hard and for just as long as usual. But to my surprise, the experience was devoid of pleasure.

    I didn’t understand why until one hot evening this summer, when I returned to Hamilton Fish, my favorite public pool in New York. It’s a sprawling, irresistible pool, flanked by trees, beautiful early-20th-century pavilions, and a plaza where people lounge about. When pools reopened during the first year of the pandemic, the city initially suspended adult hours at its outdoor pools in favor of free—and riotous—swim. When I visited, kids were shrieking with glee, horsing around and splashing everyone in sight. A handful of serious swimmers were trying in vain to find a lane for a workout, but I mainly paddled around with the kids, enjoying the cool water.

    After I did manage to find a lane to do laps, a group of kids approached me and asked if I would teach them how to do a flip turn. We had a blast practicing somersaults in the water. At closing time, after the lifeguards drove the reluctant throng out of the pool, I stood under the cold outdoor shower with the other swimmers, struck by the strange intimacy of it all: Here we were, complete strangers, a diverse collection of humanity, practically naked and standing around having fun together. Everyone got along.

    That is the whole, beautiful point of a public pool: to exercise and cool off with loads of people around. In the Southwest, where temperatures have been climbing above 100 for weeks, these facilities are a lifeline. Everywhere else, they can make the difference between a lonely, uncomfortable summer day and a joyful one. And yet, thanks to budget cuts and lifeguard shortages, fewer and fewer Americans have easy access to a municipal pool these days.

    Back in 1934, when Moses extolled the virtues of public pools, the United States was in a pool-building frenzy. Many of those pools were racially segregated, so not everyone could swim together, but in time they came to be melting pots, even as cities invested less in their upkeep and many white residents flocked to private facilities.

    Now, as the heat builds in American cities, Moses’s ideas about the role of community swimming in public health and happiness are more relevant than ever. If you can get to a public pool this summer—even if you could also use a backyard pool—make sure you take the plunge. Sure, it will still be blazing hot outside when you’re done, but the refreshment and relaxation will linger long after you’ve dried off.

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    Richard A. Friedman

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  • Medication Strategies for Treatment-Resistant Depression

    Medication Strategies for Treatment-Resistant Depression

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    Medication Strategies for Treatment-Resistant Depression

































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  • What to Know About Treatment-Resistant Depression

    What to Know About Treatment-Resistant Depression

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    What to Know About Treatment-Resistant Depression

































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  • Advances in Handling Treatment-Resistant Depression (TRD)

    Advances in Handling Treatment-Resistant Depression (TRD)

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    By Gonzalo Laje, MD, as told to Kara Mayer Robinson

    I’m a psychiatrist, board certified in child, adolescent, and adult psychiatry. After my own personal experience with depression during my 20s, I’ve been on a lifelong quest to both understand and help others.

    I spent almost a decade at the National Institutes of Health searching for ways to predict which depression treatments may be most effective for different people. Today, I manage Washington Behavioral Medicine Associates, a group practice in Chevy Chase, MD, where we help patients of all ages with treatment-resistant depression, or TRD.

    Here’s what you should know about TRD and advances in treatment.

    How do you know it’s TRD?

    Most experts would agree the definition of treatment-resistant depression is the failure of two or more antidepressants, prescribed and taken at maximum dose, for at least 6 weeks each.

    What can you do if you have TRD?

    There are many options for successfully treating TRD. However, this doesn’t mean it’s going to be easy to find successful treatment.

    My approach to TRD involves offering support from multiple angles. I don’t just focus on depression meds, but on an overall strategy that includes:

    • Dietary changes
    • Exercise
    • Medical evaluation with comprehensive bloodwork
    • Medication
    • Neuromodulation
    • Psychotherapy
    • Restorative sleep
    • Supplements and vitamins, especially if we find a deficit

    First, I find out the details of previous treatments. It’s important for your doctor to understand how your symptoms evolved and how you responded to previous treatments. Your doctor may ask which medications you tried, the doses, how long you used them, and if you had side effects.

    Then I look at the broader medical picture. Could there be other factors at play? Do you have good sleep habits, diet, and exercise?

    I may recommend supplements, vitamins, and medication to improve day-to-day life. For example, vitamin D or omega-3s may help with mood improvement. I also address the constant negative self-talk that comes with depression.

    Finally, I look for a combination of medications and neuromodulation to help your brain function in a more harmonious way.

    Which treatments are best for TRD?

    In the last 15 years, we’ve had a welcome introduction of different evidence-based strategies to treat TRD. They involve medication and techniques involving brain stimulation or inhibition, which is called neuromodulation.

    Medication. For TRD, we go beyond classic depression medications like selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs).

    We may use medications like tricyclic antidepressants, lithium, thyroid hormone, and monoamine oxidase inhibitors (MAOIs). We may combine these with other medications, like atypical antipsychotics, buspirone, or other mood stabilizers. The combination of options is enormous.

    Ketamine is an old anesthetic drug that’s been shown to help relieve TRD within hours. This is a big difference from typical depression meds, which may take weeks. There’s been some controversy around ketamine, but it offers hope for severe cases with limited options.

    Neuromodulation. This is a treatment strategy that uses physical methods, like electric currents, to stimulate your brain.

    One type is electroconvulsive therapy (ECT). It’s been poorly portrayed in movies and has fueled misinformation and distrust, but it’s a very safe and effective method to treat depression. ECT sends a small dose of electricity through your brain to change your brain chemistry and reverse your symptoms.

    Another type is repetitive transcranial magnetic stimulation (rTMS). This is an FDA-approved treatment that delivers a magnetic pulse through a coil placed in your scalp. The pulse may stimulate or inhibit nerve cells in the part of your brain that involves mood control.

    rTMS has minimal side effects and results have been positive. It’s my preferred method, and I often pair it with other treatment strategies.

    What other treatments might doctors try for TRD?

    Light therapy is a well-established treatment option for people whose depression may be seasonal. If your mood deteriorates in the fall months, it may have a seasonal component.

    Light therapy can ease symptoms, improve sleep, and increase energy. It depends on the device, but your doctor may recommend using light panels or goggles every morning for about 20-30 minutes, starting in the fall.

    Psilocybin, or “mushrooms,” has been studied as a possible depression treatment for many years. It’s not clear if it’s better than traditional antidepressants, but it may have fewer side effects. It may be an option if you’ve tried other things and they didn’t work. Talk to your doctor to see if it’s a good option for you.

    Nitrous oxide (N2O), commonly known as “laughing gas,” may help with depressive symptoms. It’s fast-acting and may be similar to ketamine. But there’s no clear strategy yet for how to use N20 for depression. This may change in the near future as more research is being done now.

    Does psychotherapy help TRD?

    Psychotherapy is an important part of your treatment strategy.

    In most cases, I favor talk therapy strategies that focus on the here and now. Therapies that help you solve problems, understand why you feel stuck, promote a healthy mind-body connection, and help you recognize and handle emotions are often the most effective.

    Depending on your situation, one type of therapy may be better than another. In many ways, I think of the different types of therapy through the same lens as different medications: Some work better for one kind of problem and some work better for others.

    What are common challenges in treating TRD?

    The first challenge is getting the right diagnosis. To find the best treatment, it’s important to understand other conditions you may have, like anxiety, obsessive-compulsive disorder, personality disorder, or other medical problems.

    Since we don’t yet have very good predictors to know if we should pick one strategy over another, it’s a process of trial and error. This can be challenging and may fuel anxiety and frustration.

    What can you do to improve your chances of finding a treatment that works?

    Work with your primary care provider and a therapist to try different strategies. It may be helpful to consult an experienced psychiatrist or psychopharmacologist.

    There are many treatment options. I’ve had many patients say, “I’ve tried them all,” “Nothing is going to help me,” or “You don’t know what it’s like.” But depression is an illness like any other. If your treatment doesn’t seem to work, it may be time to discuss other strategies with your provider.

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  • Managing Treatment-Resistant Depression: One Person’s Story

    Managing Treatment-Resistant Depression: One Person’s Story

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    When Imadé Borha graduated from Columbia University in 2015 with a master’s degree in nonfiction creative writing, she thought the last thing she’d have to worry about was finding a job. It didn’t happen. “That was around the time of the first suicide attempt,” recalls Borha, 34, now a Durham, NC-based communications professional for a nonprofit organization.

    “Career instability was triggering a lot of the mental health problems I was having,” she says. “It had felt like a failure that I had to leave New York, and not having a job” was traumatic.

    Borha was first diagnosed with major depressive disorder in 2012. “It was in response to suicidal behavior, and basically textbook depression,” she says. “When I had the first suicide attempt, that was when I noticed that the three meds I’d taken hadn’t helped.”

    Treatment-resistant depression happens when someone with major depressive disorder hasn’t responded to at least two antidepressants taken in the right dosage for the prescribed amount of time, according to Matthew Rudorfer, MD, a psychiatrist and chief of the somatic treatments and psychopharmacology program at the National Institute of Mental Health in Maryland.

    “There are clearly many shades of major depression. … There is no ‘one-size-fits-all’ solution. Rather, the best clinical intervention for the person with [treatment-resistant depression] should be personalized to the individual. A major aim of ongoing research is to improve the ability to match patients with the right treatment.”

    A New Diagnosis

    In 2019, Borha was diagnosed with borderline personality disorder (BPD), which brings mood swings, a shaky sense of self, impulsive behavior, and trouble forming relationships.

    “The symptoms of BPD include extreme, intense emotions that can be triggered by reactions like a sense of abandonment or rejection,” she says. She feels being turned down for jobs and other opportunities brought her symptoms roaring to the surface.

    Amid the mental turmoil, it took a while for Borha to tease out how much anxiety drove much of her thinking and actions. “When you’re highly suicidal, you really don’t have the time to ask, ‘Do I have an anxiety problem?’ ” In time, she tried the prescription anti-anxiety med buspirone (BuSpar). It helped quiet her mind. Along with dialectical behavioral therapy, her world began to come into focus.

    Dialectical behavioral therapy blends weekly talk therapy with group skills training. It zeroes in on emotions and takes a balanced approach to both accept oneself and learn ways to make helpful changes. It was first developed to treat BPD and women with suicidal tendencies, but now it’s used to treat other related problems, too.

    “It helps folks like me, who have really big emotions, have skills or tools to help regulate those emotions so our lives aren’t looking like chaos every single day,” Borha says. Exercise — mainly high-intensity interval training — helps keep her centered too, she says.

    Community Is Key

    “I do strongly believe that building [a mental health] community is going to keep me alive, keep my suicidal behavior and self-harm low,” Borha says. At the same time, she finds it tough to build interpersonal relationships because of her fear of abandonment and rejection. “I speak a lot, but when it comes to day-to-day interaction about my current mental health, it’s hard. I need to be more vulnerable, to put myself out there, to just be honest with people.”

    Borha says resistance to seeking treatment for mental or emotional conditions is deep-rooted in the Black community. “We’re dealing with a situation where historically, when Black people disclose they’re sad, they’re depressed, or they’re angry, they’ll be punished. They feel their lives can be in danger. That response echoes through their families and support systems.”

    Borha says the mindset to keep problems in the family, under wraps, is loosening up a little. “Now, [Black people with mental issues] have a chance to find therapists and other resources.” However, she still sees obstacles and racial bias related to care.

    Through her website, DepressedWhileBlack.com, Borha tries to link her followers with therapists who’ll understand them. Right now, her Help Me Find a Therapist program is on hiatus while her team catches up on the backlog of requests.

    Be Your Own Researcher

    “I do think treatment-resistant depression is a huge part of the suicide crisis,” Borha says. “If we can treat people who’ve struggled with it, we can save lives.”

    The antidepressant esketamine (Spravato) is the only drug the FDA has approved specifically for treatment-resistant depression, though a range of other treatments and therapies can help and continue to be studied, Rudorfer says. Esketamine comes from ketamine. It’s a nasal spray that has to be given and monitored by a health care provider.

    Borha says she’s asked her insurance to cover esketamine, but so far it’s a no-go. Meanwhile, she presses on to study and learn more about her condition.

    “I would say research your symptoms, because you may [need] a different diagnosis,” she says. “Then use that research to do self-advocacy. Tell your therapist or psychiatrist what else is out there that they haven’t considered, when it comes to diagnoses.”

    And, she says, “It’s OK to be wrong. … If psychiatrists can be wrong, I can be wrong. As patients, we have the right to experiment, and to fail, and to try again. We have that right.”

    “Just experiment, research, and go for it,” she says. “Advocate for yourself.”

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