What opportunities exist for those suffering from severe chronic depression/OCD?
I have a very close friend that has been in the deepest troughs of depression for the past couple of years. They live about an hour away, so though my wife and I try to physically show up to support them whenever we can, that's much less often than we'd like. Their support network is thin, and day-to-day basically consists of only their partner, with whom they live, and who is visibly fraying at the seams.
This person (I'll just call them John for the sake of readability) is currently on medication for their depression and OCD (I'm nearly certain it's Lexapro, can't remember for sure) and has on and off therapy, though they often find themselves at odds with their therapists' perspectives. Some of this is because it feels like the profession has been flooded with folks who lack experience with patients with severe chronic mental illness, and some of this is (I suspect) John's illness distorting their thinking, leading to frustration and anger in the moment that doesn't make sense in retrospect.
John had a particularly bad day yesterday, and after I spent some time with them, we started talking about how they felt like they needed considerably more support than they were able to get in their current situation. Unfortunately, the only option he was aware of was "group homes", which seems like a pretty broad term and I don't know much about what they look like (or how successful they are at helping people like John).
I'm trying to get a sense of the spectrum of options available for people like John who are suffering from severe chronic mental illness. On the one end, there's what we're doing now; regular psychiatry and counseling, and on the other end, I guess, is involuntary in-patient behavioral health/medicine clinics. Being involuntarily committed to such programs has been a source of trauma for them in the past, so I'd like to avoid anything even close to that end of the spectrum, if possible. I know that there are, for example, 90-day rehabilitation centers for folks with substance use disorders (I have a family member that found a lot of success at one of these), but do similar programs exist for folks non-substance-related mental illness? Does anyone have personal experience with any of these programs?
Thanks in advance to anyone who takes a moment to read and share their thoughts; I know this is a really challenging topic.
For how long has your friend been taking psych meds? Those take a while to function and you usually have to try a bunch before arriving at the best combination.
Electroconvulsive therapy is a last recourse when no medication shows any sign of improvement. It is not convenient because you can't do it in your home, and there's a small risk of memory loss in higher voltages. It's incredibly effective and the results are immediate.
I'm not well informed on the subject (many here are) but there is good research pointing to the positive effects of psychedelics in mental patients. You could seek mental health professionals that are licensed to conduct those treatments -- do not employ those substances yourself.
Committing someone is serious business and is usually done when they're a danger to others or themselves. Without sufficient need, it can do more harm than good.
Above all you must be patient. There are no quick solutions. You can always see incremental improvements, but your friend's recovery must be measured in years -- not weeks or months. And there will be moments when he'll seemingly go back to square one. This will test your resolve, but you just have to keep going. There are no guarantees, no set times. Just the goal.
As for other resources, I can't think of anything better than a loving, supporting friend. And if looks like they already got it ;)
I really appreciate your response, @lou, thank you. John’s been on this round of meds for maybe three or four months? Maybe a bit longer. But my understanding is that they often forget/fail to tale them, and without taking them every day, they’re not “building up” in their system enough to have the intended effect. I’m definitely no stranger with the need for patience when is comes to evaluating progress with mental health; in this case John has been in the worst state I’ve seen (often unable to leave their apartment, sometimes unable to leave their bed) for the past two years, with no notable improvement.
There are certainly a lot of other kinds of interventions to try (I had totally forgotten about modern electroconvulsive therapy), the problem we seem to be having is with even getting to a place where John can have the presence of mind to get out the door, or even on a Zoom call consistently enough to start any of these things.
What he’s asking for now is more help moment-to-moment; he feels like he can’t do even very simple tasks, like folding clothes or refilling the cats’ food bowls. So those are the options I’m trying to get a better sense of.
I have had ECT myself, so I can offer a perspective on it.
I had the support to be able to do ECT outpatient, but staying in hospital is an option for people who don't have that support. You're not allowed to drive yourself for the duration of the treatment, and you're not supposed to be left alone for 24 hours after each session, so it's quite a lot of support needed. Many people stay in hospital during it.
I went because of severe depression, which I ran through pretty much every medication option for, which either didn't work or had intolerable side effects. I had 7 sessions over the course of a few weeks, which dramatically improved my depression. I went from pretty much only being alive out of obligation to my spouse and not having the energy to bathe to mostly functional human.
Many people do maintenance ECT after their initial course, to prevent relapses back into depression. This is usually a single treatment every couple months or so, but it varies by person. I did not do this, because after I was out of the severely depressed rut, I found myself able to make changes in my life that prevented me from ending up there again. My core issue wasn't the depression, but untreated CPTSD and ADHD, but I couldn't make progress on addressing those issues until I got myself out of the years-long depression hole. It may be a similar situation for your friend.
ECT does have risks and side effects. You are put under anesthesia for each session, which has risks. ECT can cause memory issues. I personally do not remember the few weeks I was undergoing treatment pretty much at all. The month or two before the treatment is fairly scrambled as well, but it's hard to say how much of that is ECT and how much of it is depression rotting my brain. I can't say I have any lasting memory issues caused by it, but in rare cases people do have more significant memory problems. It also isn't generally used to treat OCD, so your friend may still need medication afterwards.
But it also has its benefits. It's more effective by the numbers than any medication antidepressant. It's fast acting, and doesn't rely on you remembering to take daily pills.
There aren't that many facilities in the US that still do ECT, because it has quite a stigma around it. My spouse had to drive me a 6 hour roundtrip for every treatment. It's also not cheap, and may take a fight with insurance to get covered.
That's pretty much everything I can think of to say about it off the top of my head, but if you have any questions, I'm happy to answer. I think my ECT treatment was 100% worth it and really helped me, and overall think it should be an option for more people.
Ketamine infusions and psilocybin are new therapies that are promising.
This hits home pretty hard, so I can speak from some personal experience. Two thoughts to share:
First, your friend may want to consider getting a pharmacogenomic test. These test the major liver enzymes to make sure that he has actual functional working copies. When I started being treated for depression, I failed drug after drug untilI finally got lucky and found one that worked. Years later, I had the same problem again when switching medications. I eventually got a pharmacogenomic test and it turned out that many of my liver enzymes are genetically not functional - I was not able to metabolize the drugs! Once I had that test, finding the right medication that I could take, wanted to take, and kept on taking was actually very easy.
Beyond medications, I would recommend looking into transcranial magnetic stimulation (TMS). It is a direct method to stimulate (or quiet) the parts of the brain responsible for depression and OCD. I have had two courses of TMS treatment (it's a series of daily treatments for a few weeks) and it worked extremely well for me. It is not at all like ECT, there is no memory loss, there are few if any side effects and there is almost no risk at all, other than it perhaps not working for someone. Definitely worth looking into, especially for treatment resistant depression and depression with OCD. For OCD, the clinic might consider "right side" TMS instead of the more standard "left side" treatment.
Thank you so much for taking the time to reply, @SweetestRug. I’m going to see them today; I want to get a better understanding of how they feel about their medication, and we can also talk about TMS and some of the other new therapies that folks have mentioned. I know that one source of challenge is that their meds really fuck with their stomach; they have bouts of nausea relatively frequently.
Definitely take the time to talk with them. Citalopram and escitalopram (Celexa and Lexapro) can cause nausea, and if any liver enzymes are impacted, this could be a major side effect.
One potential course to look at is what is colloquially known as "California Rocket Fuel" - the combination of mirtazapine with venlafaxine (Remeron and Effexor). Venlafaxine can be substituted with desvenlafaxine in some cases. There have been a few studies of the combination; the combination is known to offer relatively rapid relief of symptoms and overall better improvement than many other therapies. I do not know about how it affects OCD, but for depression it has worked for many.
Good luck! I think it's great that you are asking the right questions for your friend and he is very lucky to have you.
I was taking an SSRI that would, without fail, cause me to vomit half an hour after taking it. It wasn't the only med I was on, so I was also losing all the benefits of my other morning medication, not just the antidepressant. The SSRI worked really well, so I didn't want to jump back on the medication merry-go-round I'd been on for decades.
Instead, my psychiatrist gave me Zofran (Ondansetron), an anti-nausea drug. I'd take that about half an hour before my other meds, and it solved the issue immediately. It's something they give to people with migraines (which I also have) or who are undergoing chemotherapy, and it's been a miracle drug. If your friend has frequent nausea, that alone makes life miserable. Zofran might be something to look into regardless of other meds, if they haven't already.
I hope you can all find some solutions, and I wish you luck.
I have to make the obligatory comment about how this is a medical issue, therefore medical professionals should be the ones to give final advice.
While others have given a wide range of treatment options, I'll mention something about therapy.
You mentioned
Unfortunately, I have to agree with this. From both personal experiences and those that have been shared with me, a lot of therapists seem to make therapy feel somewhat aimless or sometimes worse - attempt to give medical advice (on supplements, diet, exercises, etc). The therapists that do know what they are doing have spent an extensive amount of time learning particular tried-and-true therapy methods, such as DBT. "Homework assignments" that lean on these therapies and teach you to manage situations differently should be the norm.
This is also something a good therapist can help you work through. You have to find someone you can comfortably discuss this with (though it may only be something you can discuss when you're in a more stable state of mind). I recently had conflict with my therapist that I discussed, and while it was challenging, I realized that my therapist was on my side and wanted to ensure I felt heard.
Therapy is hard work, and it doesn't (and shouldn't) always make you "feel better" after each session. You'll be working through challenging emotions that can be overwhelming and painful. So if you notice John is feeling particularly rough after a therapy session, it's possible that's actually a good thing, long term.
Hopefully this helps.
How long do the effects last? Is it something you need to keep doing regularly or is it permanent/semi-permanent?
I second everything @literallytwisted said. And want to commend OP for sticking with your friend through this. I guarantee it means the world to them.
@smores, one thing I’d like to add is to make sure you’re taking care of yourself (which it sounds like you are) and putting your “oxygen mask” on before you put it on others. Unfortunately, it sounds like your friends partner is not prioritizing their own care and may be dealing with Caretaker Burnout. My recommendation would be to try and give your friend’s partner a relaxation or self-care day. Make sure they have people to talk to about their day-to-day life other than their partner and that they have hobbies and a life outside of work or caretaking — or, well, try your best to encourage those things.
I’d also like to add a word of caution about ketamine, shrooms, and psychedelics. Some of them don’t mix well with meds your friend might be on. And studies on their efficacy are done in regulated environments (not just by themselves at home). Lots of people like to act like they’re a silver bullet (and maybe they are for some) but there’s no guarantee.
Best of luck to you and your friend.
Thank you so much for your reply @literallytwisted. His partner brought up day programs; it's not something I'm familiar with, but it seems worth looking into more. If you have any more info (or just resources, happy to do the reading myself!) I would really appreciate it. A challenge that John and I foresee with day programs (not an insurmountable one, necessarily!) is that there are days where we expect he simply won't be able to bring himself to go to the day program, and those are the days when he presumably will need the most support.
Separately, my brother had a lot of success after going to a 90-day rehab facility for his various substance use disorders; do you know if there are similar programs for non-substance related mental illness? I feel like there must be, but I also know that the way we think about and treat substance use disorders relative to other mental illness can be very weird and lop-sided.