They are saying my mum is resistant to medicines tried so far.. What next?

[JoeyLin]

My mum is 65. She has been on sertraline, then a combination of Mirtazapine and Venlafaxine.. Now they are going to try fluoxtine ..

However, they have increased doses and changed.. but still no change to her mood. Brain scan has come back clear. She has also taken olanzapine.

What would be next after these class of medicines?

What is the root cause of her unhappiness?

Has she always had MH problems? I thought "treatment-resistant depression" was code for "has a personality disorder but suspect they'll get upset if we tell them that".

Hi both, for more context - my mum was not depressed until 4 years ago.
She first became 'down', then following a UTI that sent her manic for a few days, she has been very anxious and depressed - doing nothing in her daily life unless told.
We cannot find a root cause - she has not opened up in 4 years no matter what we try. Therepy will not work on her at the moment because she is just closed, quiet and anxious.
Everytime she has changed medicine, we see a slight improvement - she may leave the house willingly to see her children or talk better. but after a couple of weeks its back to sq1. She doesn't use her phone, hardly partakes in self-care, and eats / cooks very last minute. She is very different to who she was - i.e. sociable, caring, pro-active with cooking etc.

This is incorrect, and not a very kind of helpful thing to say.

Untreatable depression can sometimes be undiagnosed ADHD (inattentive is common in women). She might need dopamine not seratonin etc. My 70ish mum (and me, now dx’d) both have had similar experiences.

@EleanorLucyG i have been told I have treatment resistant depression. Pretty sure my treating psychiatrists aren’t concealing a personality disorder diagnosis from me - they continue to use depression specific treatments including ECT and referred me to a specialist unit which specialises in managing treatment resistant mood disorders. Please be careful about making comments like this - comes across as ill informed, unhelpful and potentially offensive.

@JoeyLin there’s quite a lot of other options which might be suitable for your mum including different antidepressants that work in different ways eg vortioxetine or different augmentation strategies like lithium. Hard to say without knowing her what they’ll go for next but just to reassure that there are lots of options. I hope she recovers soon.

No it means people who can’t find a drug to suit them or they don’t work.

I was treatment resistant. Eventually ended up on Venlafaxine. Took a psychiatrist nearly 2 years to sort me. I just had anxiety and depression.

Has she seen a psychiatrist?

Ketamine is available in some places. That’s meant to be good for treatment resistance.

There's a mood disorder service called Maudsley in London who specialise in this area. You can be referred via a psychiatrist. They really helped me

It could possibly be that the UTI/manic episode scared her subconscious mind so badly that it now vetoes everything in case it recurs - a classic trauma response. She won't be consciously aware of this, just of the resulting fear and inability to do anything. She could try remedial hypnosis or EMDR, neither of which require her to discuss her feelings in depth.

Yeah EMDR is good.

Thank you all - so in the last consultation with her mental health Dr - they said they will try this move to Fluoxetine. After this, Lithium is being mentioned.

My partner works in mental health and he has suggested some 'older skool' drugs be considered such as Amitriptyline and duloxetine.

Tbh, we are lost. Therepy won't work as she doesn't communicate. She has no quality of life. She can be 'dragged' places (not physically, but with persistence), but she lacks motivation. The hardest part is I have a daughter now (her grandchild), and even that hasn't helped motivate her to do stuff. Everything is last minute and with a panic. The olanzapine was there for anxiety or masked anti-pychosis but we always believed she wasn't pychotic - the incident with UTI was very specific to that time. Since she stopped olanzapine herself a few months ago - there has been no change positive or negative.
We did an MRI, because I was adamant that UTI caused some long-term damage. but it has come back clear - which I'm thankful for.

Look - we will come off Venlafaxine now and switch to Fluoxetine. But its more to tick box, i think we all know it won't change things.

I would like to add, that when she has made it to a social setting OR visit her grandchild - she can at times act completely 'fine' - and be social and great talker and play with the children. So there are glimpses there of her old self.
This is why we have some hope. Her memory is good - her knowledge is good.

Has she not been tried on the old school ones?

Amitryptiline is the gold standard. Chlomiprimine is the most powerful one to hit serotonin out of any of them old and new.

No - she has not tried. Tbh I am not aware of the concept of new and old skool till recently. Consultant has said her age is a factor.
But its giving me hope that this isn't the end of the line.

I don't like to mention it but could she have dementia?Apathy and depression are common. It's not that unusual to start in someone's early 60s.

She's right at the start of medication options if I'm honest - in the last 5 years, I've been on about 15 different meds, sometimes alone and sometimes in combination until I've found the one that works best for me. A good psychiatrist will have much better access and knowledge about different options for her. There's definitely hope!

I’m sure they have checked this, but have they ruled out a chronic low-grade uti? She might not be reporting symptoms.

I would be far from losing hope. I tried citalopram (zombie me) setraline (upset tum) mirtazapine (so sleepy I couldn’t function.)
i am now on fluoxetine. It’s been a miracle for me. I can function. I can be happy. I can plan things and look forward to the future. My mood is pretty much totally stable and my anxiety is completely under control.

Don't lose hope. lithium is a great option, and so is Amitryptiline

Does she want to change the way she thinks, feels and behaves? Or is she unaware of her situation?

Has she been assessed for Dementia or Alzheimer’s? What other medication is she on? When did she start menopause? Could it be that?

Hi - for those asking about dementia, her consultant is not concrened. Her memory recall, story telling ability and appropriatness is really good in those moments.
One of you have mentioned scaring of subconcious from the UTI - I'm so glad someone also see's this. It is why we did the MRI. However it came back clear.

Thing is, the UTI happened quite early on - but before it she was just a bit 'down', sertraline would pick her up . after the UTI and she thought people were after us.. there is an element of panic and anxiety in her that has NEVER gone away - even with all the meds and combinations. She has had UTI again a few time - its hard to get her to drink enough water.

@Eyesopenwideawake - i dont think daily she understand her situation. But if really pressed to talk she will express sadness on how her family are suffering because of her and she has said to the Dr how she wants to be better. But she cannot put this into any tangible steps on how to get better.

Memory loss is not the first symptom in all types of dementia. It depends which parts of the brain are affected first.
Another possibility is that she has delirium because of the UTI. UTSs can play havoc with older people and cause delirium.

Do you know for sure what your mum's cooperation is like with the meds she's tried so far? As in is she taking them regularly? May sound like a silly question but if she is feeling anxious then she might be worried about taking them as the side effects can be quite unpleasant at first.

There are still plenty of options, amytriptaline, lamotrigine maybe. I understand she may not engage well at first with a longer term talking therapy such as psychoanalysis if she won't open up but maybe one that's a bit shorter term and focussed on outcomes like doing her normal activities such as CBT might be worth a try?