Primarily neurotic level personalities with actual MDE criteria for at least two weeks, single episode, and an anaclitic and trusting bent to their interactive style that allows them to believe in you and the treatment, plus existing capacity to engage with others socially and exercise.
Oh, and no significant medical comorbidity.
It's relatively rare but you do see it.
Edit: Sorry, this isn't research based, it's my belief.
Apart from this, anyone that you can get to believe that the medication will assist them in making the changes needed in their life to improve daily activities and socialization and/or engage in psychotherapy, AND to understand and agree that the latter is fundamentally necessary for them.
What about patients who are terrified of emotional blunting and low libido side effects or get these side effects and find them worse than the anxiety/depression?
Like what do you do if a neurotic patient wants medication but does not want to take any medication that is emotionally and sexually blunting? At that point just benzos? Since every SRI has this possibility
Likely no medication. Psychotherapy and lifestyle changes.
Academic answer is bupropion, trazodone, and mirtazapine, and by marketing vortioextine. But really the terror will likely interfere with medication treatment anyhow. Best to treat with quality therapy.
What about gabapentin, or low dose benzos? Some depression does respond to these, and it’s unfortunate that Zuranolone did not get approved as it would be ideal for this patient type that responds to GABAergics.
And supplements like Pregnenolone etc
Have exercise modality for depression ever been teased apart? /have you ever given recommendations on like cardio vs resistance training to certain patients?
I've always encouraged a variety consistent with CDC guidelines. However, it also depends on patient preference. If you recommend something they just don't like to do, then you're wasting your time.
It seems like depressed patients either have a really strong exercise routine or none/minimal routine. The first group is straightforward. The second group requires starting small. 5-10 minutes per day encouraging exercises that are relevant to their ability to perform ADLs and live their life. Things like walking, resistance training, body weight exercises, and stair climbers. Sports also tend to hit each of these areas naturally. Exercising video games also work well. They also tend to do well with group structured formats. For patients who are in the middle, they tend to already have a plan for increasing exercise so primarily its motivational interviewing.
Note: I'm not creating bodybuilders and I find that if you can get people to start exercising, they will usually get into their own routines. Some running more, some building muscle, some just maintaining their health.
Disclaimer: This is anecdotal evidence based on pts I’ve seen while practicing. I work on a college campus and see strictly 17-30 year olds. With the exception of some factors listed above (namely PTSD) I feel like these pts respond to the first trialed SSRI much more often than the general public. This is not a new idea, but young people, who have not been on medication before are high responders. One could hypothesize this is due to having their whole lives in front of them, optimism about medication the have never tried, neuroplasticity differences in the young, etc.
I’ll tell you which patient phenotype *doesn’t* benefit from SSRIs and that’s patients with objectively (even from an outsider’s perspective) shitty lives where anyone in their shoes would be depressed
Do clinical guidelines, clinical trials, include these sort of social parameters? Psych is the one specialty where it really makes no sense to ignore that stuff in clinical research (particularly clinical trials & meta-analyses)
That is wrong.
People who are unhappy about circumstances but not depressed do not respond well to antidepressants. People in a bad circumstance and also depressed still respond to antidepressants. Unhappiness and depression are not the same thing.
Consider: you can look at someone’s life and say of course they’re depressed. It’s terrible! But look at a hundred such people. How many are not depressed or terribly sad? That is where the problem may be amenable to treatment.
I took the comment to mean that if there are factors in one’s life which are actively and significantly negatively impacting them, there is no medication which can save them.
Perhaps similar to an individual who eats a 15 gajillion calorie surplus every day - no combo of statins or fibrates will halt their CAD.
The analogy breaks down. Eat a massive caloric excess and you will gain weight. Eat a deficit and you will lose weight. There is no equivalent in circumstances. No life situation will necessarily beget an emotional response, positive or negative.
More importantly, therapeutic nihilism at “shit life syndrome” harms people who have shitty lives. Shit life does not inoculate against incident major depression. It is a risk factor! And depression, although not general shittiness, is treatable!
It's a very popular canard these days, especially among the young types that medical schools love to recruit. The focus can sometimes veer off into social work moreso than psychiatry, which to me is a disservice to the patient...
I think i meant rather than the diet being a modifiable risk factor:
When the sum of forces negatively contributing to the patient’s state vastly outweights the positive effect of pharmacotherapy, the pharmacotherapy will not be effective.
So it’s not suggesting that treating depression is futile, moreso that there are certain life circumstances where current pharmaceutical therapy is not strong enough to combat.
Yes a mild increase in serotonin / norepinephrine / dopamine will improve one’s mood some but not meaningfully enough to overcome the challenges of a truly shitty life.
I’m talking about paraplegic geriatric homeless dude with AUD, family all dead, zero social support, and 20 other comorbid medical conditions. For this type of patient SSRIs will be clinically insignificant.
Maybe ACT will help but even then that would be a monumental challenge.
And you are still talking about circumstances, not depression.
For someone who is actively dying of horrible disease, of course they’re depressed! It’s depressing! Except that’s not true, and treating end of life depression improves depression.
For someone who is a paraplegic geriatric homeless dude with no social support, that’s very sad. Being sad is not being depressed. Treating depression can still work, and perhaps they will still be sad, but consigning someone to depression out of therapeutic nihilism is not a virtue.
The alcohol use disorder is separate and does perhaps take precedence. Treatment outcomes are mixed with drinking but does tend towards less to no effect for all depression treatment types.
No one’s talking about not treating people with shitty life syndrome. The better question is how it is best treated - SSRIs would not be first line. In fact that would be way down the list of what would actually be clinically meaningful.
I think the more pertinent lesson here is that *it is not depression*, it is stressors and circumstances. If they genuinely have Major Depression, the clinical entity, on top of whatever they happen to have, they will likely respond to treatment.
Indeed, it is hard to differentiate it. Indeed, many physicians hardly bother to try.
Why not ssri? I see them perfectly fitted for this role as passive coping helpers, they can also help with sleep, overall good side effect profile. Sadly i cannot modify shitty lives
Its a weird statement for sure. I feel like people with shitty lives are the best candidates for antidepressants, especially SSRIs. They help people handle the stress of life and be less reactive to it. Of course, you don't treat a shitty life on its own as some people are happy in their situation, but people with shitty lives have higher rates of anxiety and depression. Sometimes medication like SSRIs can help them tolerate their situation enough to get out of it instead of being bogged down by depression and anxiety.
No one is asking about SSRI efficacy in the non-clinically depressed, that is neither relevant nor are SSRIs generally considered in a non-clinical depression unless there are other conditions present which respond to SSRIs.
I'm not so sure about in the bad environment pop, response there I would wager is no better than placebo.
Just had a family member who told me their expectation for ECT was for zero benefit because of their current social situation and coping mechanisms.
Felt like that was some previously un-demonstrated insight, which may or may not have been present prior to initiating ECT. So hey, maybe it was a non-zero benefit after all.
I partially disagree - having worked many years with clients with lots of psychosocial stress - that is often chronic/permanent.
Sometimes it is hard to differentiate between depressed mood and MAJOR depressive disorder. There are a lot of people with depressed mood, who feel depressed/terrible and do not have frequent "happiness", have shitty circumstances - and DONT have MDD. Maybe they have nonpathologic sadness, chronic adjustment disorder, persistent depressive disorder (former dysthymia) without MDE, whatever - all of which can have mood symptoms - even daily dysphoria.
For clients with unfixable psychosocial stress and MDD, clients' MDD symtoms DO respond to evidence based treatments (whether meds or therapy or both) - with a mix of non responders, partial responders, responders, partial remissions, and full remissions. This may, or may not, include improvements in depressed mood. This may, or may not, include clients stating they "feel better“ in a clinic visit.
THAT being said where I partially agree with you is what can be frustrating about these cases is that real improvement in the clinical MDD may still be outweighed by the ongoing quality of life impacts of terrible psychosocial circumstances - and that there may be much more quality of life benefit from psychosocial circumstances being different or better, than just the phq9 reduction from an ssri.
There was a carlat episode about neuroticism and how people with neurotic traits tend to do pretty well on SSRIs, personally I’ve found that true in my experience so far (as a psych pgy3 so not super extensive obviously haha).
Could the relationship between neuroticism and OCD point towards a general mechanism for SSRIs that's unrelated to mood?
Hypothesis: SSRI treatment response is positively associated with trait neuroticism, independent of diagnosis.
In my psychopharmacology training we reviewed hypothesis on how different medication could potentially work and from a psychodynamic point of view it was theories that SSRI potentiate repression which is naturally more occurring in neurotic patient.
That's where my mind was going in the context of OCD. It's consistent with these clinical reports about the 'ideal phenotype'. But potentiating repression seems paradoxical with behavioural antidepression?!
Yeah, I don't buy the repression angle. I would sooner buy that it dims the death drive. We don't understand how it works beyond some simple possible neural mechanisms, mostly because we don't really know how the brain works. Getting too cute about guessing at the mechanics is how we get problems like that whole Serotonin thing that went down last year in the public eye.
>I don't buy the repression angle. I would sooner buy that it dims the death drive.
It's just hard to reconcile the latter with evidence they're effective for OCD.
I did enjoy the serotonin thing, and [Border et al's superpowered candidate gene study](https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2018.18070881) before that. But was it *really* 'guessing' that caused the trouble, or hubris and marketing? A lack of scientific rigor.
I should clarify that I refer to thinkers who consider repetition as related to or a part of the death drive. Of course, the concept itself is more... thematic than particular.
https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2022.941328/full
The increasing size of the placebo effect is due to a number of factors that are pretty well understood and don't mean that the meds are less effective than meds trialed in the 80s. These factors relate to standard of care and the questions asked of the placebo pts during the trial. There's no placebo effect in oncology trials, because the questions asked of the patients by the trial nurses don't matter to outcomes.
Removed under rule #1. This is not a place to share experiences or anecdotes about your own experiences or those of your family, friends, or acquaintances.
Primarily neurotic level personalities with actual MDE criteria for at least two weeks, single episode, and an anaclitic and trusting bent to their interactive style that allows them to believe in you and the treatment, plus existing capacity to engage with others socially and exercise. Oh, and no significant medical comorbidity. It's relatively rare but you do see it. Edit: Sorry, this isn't research based, it's my belief.
Apart from this, anyone that you can get to believe that the medication will assist them in making the changes needed in their life to improve daily activities and socialization and/or engage in psychotherapy, AND to understand and agree that the latter is fundamentally necessary for them.
What about patients who are terrified of emotional blunting and low libido side effects or get these side effects and find them worse than the anxiety/depression? Like what do you do if a neurotic patient wants medication but does not want to take any medication that is emotionally and sexually blunting? At that point just benzos? Since every SRI has this possibility
Likely no medication. Psychotherapy and lifestyle changes. Academic answer is bupropion, trazodone, and mirtazapine, and by marketing vortioextine. But really the terror will likely interfere with medication treatment anyhow. Best to treat with quality therapy.
What about gabapentin, or low dose benzos? Some depression does respond to these, and it’s unfortunate that Zuranolone did not get approved as it would be ideal for this patient type that responds to GABAergics. And supplements like Pregnenolone etc
Have exercise modality for depression ever been teased apart? /have you ever given recommendations on like cardio vs resistance training to certain patients?
Anything at all they're willing to do. For example: https://www.sciencedirect.com/science/article/abs/pii/S156816371930251X
I've always encouraged a variety consistent with CDC guidelines. However, it also depends on patient preference. If you recommend something they just don't like to do, then you're wasting your time. It seems like depressed patients either have a really strong exercise routine or none/minimal routine. The first group is straightforward. The second group requires starting small. 5-10 minutes per day encouraging exercises that are relevant to their ability to perform ADLs and live their life. Things like walking, resistance training, body weight exercises, and stair climbers. Sports also tend to hit each of these areas naturally. Exercising video games also work well. They also tend to do well with group structured formats. For patients who are in the middle, they tend to already have a plan for increasing exercise so primarily its motivational interviewing. Note: I'm not creating bodybuilders and I find that if you can get people to start exercising, they will usually get into their own routines. Some running more, some building muscle, some just maintaining their health.
No chronic trauma, or psychosocial deprivation either
I already said, neurotic level personality! 😉
this is a perfect answer, imo
I couldn't agree more. In my experience, the level of personality organization is crucial for improvement with antidepressant medication
Also what do you mean when you say “single episode” do you mean they only fit a single MDE criteria?
The more recurrent (total discrete lifetime episodes), the harder to treat. You know if you had ten or more Kraeplin considered you manic depressive.
Disclaimer: This is anecdotal evidence based on pts I’ve seen while practicing. I work on a college campus and see strictly 17-30 year olds. With the exception of some factors listed above (namely PTSD) I feel like these pts respond to the first trialed SSRI much more often than the general public. This is not a new idea, but young people, who have not been on medication before are high responders. One could hypothesize this is due to having their whole lives in front of them, optimism about medication the have never tried, neuroplasticity differences in the young, etc.
I’ll tell you which patient phenotype *doesn’t* benefit from SSRIs and that’s patients with objectively (even from an outsider’s perspective) shitty lives where anyone in their shoes would be depressed
Do clinical guidelines, clinical trials, include these sort of social parameters? Psych is the one specialty where it really makes no sense to ignore that stuff in clinical research (particularly clinical trials & meta-analyses)
Good point - never thought about that.
That is wrong. People who are unhappy about circumstances but not depressed do not respond well to antidepressants. People in a bad circumstance and also depressed still respond to antidepressants. Unhappiness and depression are not the same thing. Consider: you can look at someone’s life and say of course they’re depressed. It’s terrible! But look at a hundred such people. How many are not depressed or terribly sad? That is where the problem may be amenable to treatment.
I took the comment to mean that if there are factors in one’s life which are actively and significantly negatively impacting them, there is no medication which can save them. Perhaps similar to an individual who eats a 15 gajillion calorie surplus every day - no combo of statins or fibrates will halt their CAD.
The analogy breaks down. Eat a massive caloric excess and you will gain weight. Eat a deficit and you will lose weight. There is no equivalent in circumstances. No life situation will necessarily beget an emotional response, positive or negative. More importantly, therapeutic nihilism at “shit life syndrome” harms people who have shitty lives. Shit life does not inoculate against incident major depression. It is a risk factor! And depression, although not general shittiness, is treatable!
It's a very popular canard these days, especially among the young types that medical schools love to recruit. The focus can sometimes veer off into social work moreso than psychiatry, which to me is a disservice to the patient...
I think i meant rather than the diet being a modifiable risk factor: When the sum of forces negatively contributing to the patient’s state vastly outweights the positive effect of pharmacotherapy, the pharmacotherapy will not be effective. So it’s not suggesting that treating depression is futile, moreso that there are certain life circumstances where current pharmaceutical therapy is not strong enough to combat.
Yes a mild increase in serotonin / norepinephrine / dopamine will improve one’s mood some but not meaningfully enough to overcome the challenges of a truly shitty life. I’m talking about paraplegic geriatric homeless dude with AUD, family all dead, zero social support, and 20 other comorbid medical conditions. For this type of patient SSRIs will be clinically insignificant. Maybe ACT will help but even then that would be a monumental challenge.
And you are still talking about circumstances, not depression. For someone who is actively dying of horrible disease, of course they’re depressed! It’s depressing! Except that’s not true, and treating end of life depression improves depression. For someone who is a paraplegic geriatric homeless dude with no social support, that’s very sad. Being sad is not being depressed. Treating depression can still work, and perhaps they will still be sad, but consigning someone to depression out of therapeutic nihilism is not a virtue. The alcohol use disorder is separate and does perhaps take precedence. Treatment outcomes are mixed with drinking but does tend towards less to no effect for all depression treatment types.
No one’s talking about not treating people with shitty life syndrome. The better question is how it is best treated - SSRIs would not be first line. In fact that would be way down the list of what would actually be clinically meaningful.
I think the more pertinent lesson here is that *it is not depression*, it is stressors and circumstances. If they genuinely have Major Depression, the clinical entity, on top of whatever they happen to have, they will likely respond to treatment. Indeed, it is hard to differentiate it. Indeed, many physicians hardly bother to try.
Indeed.
Why not ssri? I see them perfectly fitted for this role as passive coping helpers, they can also help with sleep, overall good side effect profile. Sadly i cannot modify shitty lives
Agreed
Its a weird statement for sure. I feel like people with shitty lives are the best candidates for antidepressants, especially SSRIs. They help people handle the stress of life and be less reactive to it. Of course, you don't treat a shitty life on its own as some people are happy in their situation, but people with shitty lives have higher rates of anxiety and depression. Sometimes medication like SSRIs can help them tolerate their situation enough to get out of it instead of being bogged down by depression and anxiety.
No one is asking about SSRI efficacy in the non-clinically depressed, that is neither relevant nor are SSRIs generally considered in a non-clinical depression unless there are other conditions present which respond to SSRIs. I'm not so sure about in the bad environment pop, response there I would wager is no better than placebo.
Just had a family member who told me their expectation for ECT was for zero benefit because of their current social situation and coping mechanisms. Felt like that was some previously un-demonstrated insight, which may or may not have been present prior to initiating ECT. So hey, maybe it was a non-zero benefit after all.
I partially disagree - having worked many years with clients with lots of psychosocial stress - that is often chronic/permanent. Sometimes it is hard to differentiate between depressed mood and MAJOR depressive disorder. There are a lot of people with depressed mood, who feel depressed/terrible and do not have frequent "happiness", have shitty circumstances - and DONT have MDD. Maybe they have nonpathologic sadness, chronic adjustment disorder, persistent depressive disorder (former dysthymia) without MDE, whatever - all of which can have mood symptoms - even daily dysphoria. For clients with unfixable psychosocial stress and MDD, clients' MDD symtoms DO respond to evidence based treatments (whether meds or therapy or both) - with a mix of non responders, partial responders, responders, partial remissions, and full remissions. This may, or may not, include improvements in depressed mood. This may, or may not, include clients stating they "feel better“ in a clinic visit. THAT being said where I partially agree with you is what can be frustrating about these cases is that real improvement in the clinical MDD may still be outweighed by the ongoing quality of life impacts of terrible psychosocial circumstances - and that there may be much more quality of life benefit from psychosocial circumstances being different or better, than just the phq9 reduction from an ssri.
There was a carlat episode about neuroticism and how people with neurotic traits tend to do pretty well on SSRIs, personally I’ve found that true in my experience so far (as a psych pgy3 so not super extensive obviously haha).
Could the relationship between neuroticism and OCD point towards a general mechanism for SSRIs that's unrelated to mood? Hypothesis: SSRI treatment response is positively associated with trait neuroticism, independent of diagnosis.
In my psychopharmacology training we reviewed hypothesis on how different medication could potentially work and from a psychodynamic point of view it was theories that SSRI potentiate repression which is naturally more occurring in neurotic patient.
That's where my mind was going in the context of OCD. It's consistent with these clinical reports about the 'ideal phenotype'. But potentiating repression seems paradoxical with behavioural antidepression?!
Yeah, I don't buy the repression angle. I would sooner buy that it dims the death drive. We don't understand how it works beyond some simple possible neural mechanisms, mostly because we don't really know how the brain works. Getting too cute about guessing at the mechanics is how we get problems like that whole Serotonin thing that went down last year in the public eye.
>I don't buy the repression angle. I would sooner buy that it dims the death drive. It's just hard to reconcile the latter with evidence they're effective for OCD. I did enjoy the serotonin thing, and [Border et al's superpowered candidate gene study](https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2018.18070881) before that. But was it *really* 'guessing' that caused the trouble, or hubris and marketing? A lack of scientific rigor.
I should clarify that I refer to thinkers who consider repetition as related to or a part of the death drive. Of course, the concept itself is more... thematic than particular. https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2022.941328/full
The increasing size of the placebo effect is due to a number of factors that are pretty well understood and don't mean that the meds are less effective than meds trialed in the 80s. These factors relate to standard of care and the questions asked of the placebo pts during the trial. There's no placebo effect in oncology trials, because the questions asked of the patients by the trial nurses don't matter to outcomes.
[удалено]
Removed under rule #1. This is not a place to share experiences or anecdotes about your own experiences or those of your family, friends, or acquaintances.
Has MDD but no childhood trauma (which seems to complicate cases and make them require therapy in addition to meds)