Dec 22, 2022

Interviewer: When depression or bipolar disorder isn't responding to standard treatments, they are referred to as treatment-resistant mood disorders.

Psychiatrist Dr. Brian Mickey from Huntsman Mental Health Institute's Treatment-Resistant Mood Disorders Clinic is an expert at treating these conditions, and today he's going to tell us how visiting a specialist can help people suffering from this condition live happier and more productive lives.

Dr. Mickey, first, when does a treatment-resistant mood disorder become classified as treatment-resistant?

Dr. Mickey: There's no kind of magic formula, but in most cases, we consider if you've had at least two adequate trials, meaning medication trials, psychotherapy trials, that are robust and that lasted long enough and you didn't respond, we would consider that treatment-resistant.

Interviewer: Either through medication or through psychotherapy, you would have to go through at least two of those. And if you weren't seeing an improvement of the symptoms, that would be classified as treatment-resistant.

Dr. Mickey: Right. Exactly.

Interviewer: Okay. When a patient comes to you after it being identified as potentially treatment-resistant, what are the interventions that you offer then initially?

Dr. Mickey: So some of the initial options that we would discuss would be changes to their current medication regimen. That would be a common one. Sometimes people haven't had an adequate treatment trial.

Another option that we would offer within our clinic would be transcranial magnetic stimulation. That's a non-invasive brain stimulation treatment.

We also can offer ketamine infusion therapy. That's an intravenous ketamine infusion that can be helpful for depression.

And so if these less invasive options aren't effective or cause too many side effects, then there are other surgical options that we sometimes will go to next.

Interviewer: Tell me more about the less invasive options. How long do you try those? How many of those do you go through before you kind of get to that point?

Dr. Mickey: That depends a lot on the particular patient, the kind of depression they're having, how severe it is, and, of course, insurance coverage. But typically for people who are functioning fairly well, they're going to work or doing their daily routines, then transcranial magnetic stimulation or ketamine infusion therapy can make the most sense.

Transcranial magnetic stimulation and ketamine infusion therapy are more compatible with maintaining your kind of regular daily routine and the side effects are relatively low for those as well.

For people who have had more severe depression that has been very debilitating or is preventing them from working, or let's say they're admitted to the hospital, then electroconvulsive therapy, or ECT, is what we would think of probably before those other treatments.

Interviewer: Are people intimidated by that name, the fact that you're using electrotherapy? I mean, that could sound kind of scary.

Dr. Mickey: Yeah, I think it can sound scary and if you don't know too much about it or if you only know what you've learned in the movies, then it's very scary.

Interviewer: And what happened like 100 years ago. It's not that anymore.

Dr. Mickey: Yeah, it's very different and it's a very safe treatment. It does have side effects and we counsel people about that, but it can really change the game for people with severe depression.

Interviewer: It sounds like you have a lot of options and tools at your fingertips to help somebody who has gone through some initial treatments and has not been able to handle the symptoms, take care of the symptoms in a way that they're able to go back to their life.

Tell me about a typical patient that walks into your office. Describe what that looks like and the conversation you have.

Dr. Mickey: So a typical patient that we see would come feeling pretty hopeless, I would say, because they've tried many different kinds of treatments and feeling like they've gotten to the end and they don't know what else there is to try.

Typically they've had years of illness, if not decades. And most people that we see also have had this illness since they were very young. So, most of the time, the onset of their illness is in their teenage years or young adulthood.

Typically, people are not able to enjoy life. They're not enjoying their work. They're not enjoying their social interactions. They become less interested in pursuing hobbies and being with other people. Most people have then become kind of socially disconnected, and that can even make things worse, because that's . . .

Interviewer: Yeah, and not finding satisfaction in work. Do these individuals realize that this is happening and are like, "I would love to find satisfaction in my work, but I just can't"?

Dr. Mickey: Right. Most people do, and the way they experience it is usually they're not sure why they're not enjoying it. And of course, we all have stress in our lives, but these are situations where the amount of sadness and mood dysregulation and loss of interest and pleasure is far beyond that. It doesn't make sense in the context. That's kind of what we're talking about here when talking about depression.

Those are the kinds of experiences and symptoms people are having before they're coming to our clinic. And what these treatments can do is they relatively quickly, within a few weeks, start to relieve people of those symptoms. And then the effects can last for months or sometimes even years before people will very often have a relapse.

And so that's something that we also educate people about. This is not a cure. It's a treatment that we can administer for this episode. But that can be a really meaningful difference for people.

Interviewer: And then if a relapse occurs, what then?

Dr. Mickey: For people who've had a recurrence, then we can oftentimes use these same treatments. And so we don't think of them as permanent fixes obviously. And so people will always have this kind of vulnerability. That would be the most typical pattern, that people have recurrences.

But if you understand the patterns, sometimes you can prevent them. That's the ultimate goal, is to prevent a recurrence. But if people do have a recurrence, then we can use these treatments again. And so those are the folks that we see and that I think we can help.

Interviewer: And for those individuals that have suffered for decades, what's the barrier to seeking out more treatment?

Dr. Mickey: There are a number of barriers. One is not knowing about what options there are beyond the things they've already tried. Another is oftentimes just insurance barriers.

Another barrier that people have I think is just fear of the unknown, kind of maybe not quite understanding what these treatment options are really like, which we can help educate people about that.

And then I think another is just that a lot of times people don't want to be a depressed person. It's not a great place to come from. And so you have to sort of admit that you have this condition before you're really going to come to the clinic. I think that can be a barrier as well.

Interviewer: Do you find it common that somebody that is suffering from a treatment-resistant mood disorder is not able to seek out help on their own and generally a family member is needed?

Dr. Mickey: It is pretty common. And I think part of it is that they may not want to think of themselves as a depressed person or they may not realize in some cases how severe things are.

And that's one thing that depression does, is it changes how you see yourself and how you think about the world. It makes you more kind of internally focused and less able to appreciate how far things have gotten in many cases. And I think sometimes people just don't remember how they were when they weren't depressed. So it has these effects on your own cognition and understanding of yourself, which kind of makes it unique.

Interviewer: You mentioned insurance can be a barrier for some people. Is there somebody at Huntsman Mental Health Institute that if somebody is concerned about "How am I going to pay for this?" that could help walk that individual through maybe some of the options if insurance isn't the option?

Dr. Mickey: Yeah, absolutely. In our clinic, we have referral specialists who will do all of those checks ahead of time and help you understand what the financial situation is. You don't want to go into a situation like this and not know what the cost will be. And there's nothing like an extra bill to accentuate your depression. So, yeah, that's an important aspect of the care that we pay a lot of attention to.

Interviewer: Well, it sounds like that you are offering hope to some people that have struggled with mood disorders for a long, long time. As we wrap this up, is there anything that you would say that you would like the listener to take away from our conversation today?

Dr. Mickey: Yeah, I would say that there is hope. And that's a very common reply or response that we get from patients at the end of a consultation. They're often saying, "I didn't even know there were all these options." It's pretty common actually for people to feel quite a bit better just after this single consultation visit before we've even administered any active treatments.

For Patients