expectations and therapy for mood disorder

June 17, 2021 8:32 PM

Trying to figure out what expectations are reasonable for someone whose symptoms keep returning despite 18 years of weekly therapy. Should my mental health have gotten better by now, or is something else going on? (discusses suicidal ideation)

I have a mood disorder "not otherwise specified" which for me means long periods of very high functioning stability punctuated by acute, severe depressive episodes that involve suicide attempts and hospitalization. These episodes happen even though I "do the work" (take my medications as prescribed, avoid alcohol & other substances, practice self care like exercise and socializing, and never miss a therapy session). The episodes never come out of nowhere; they're always triggered by the exact same type of external circumstance (interpersonal loss/grief or relational trauma).

I have lived like this for 18 years now and because there is such a clear pattern, I am wondering if I have not had the right therapists or type of therapy. Otherwise, I assume I would have seen some sort of improvement or progress, right? Or, is my problem that really terrible things (deaths, abuse) simply keep happening to me and would make anyone miserable? I'm in a grief support group where suicidal ideation seems almost universally common - I don't really know what "normal" looks like for someone who has had my set of life experiences. I do know that I don't want my life to stay this way, though. I guess a third possibility is that I have some sort of intractable, treatment resistant mental condition.

For reference, I have tried CBT, DBT, mindfulness, psychoanalysis, psychodynamic therapy, groups, and EMDR - everything but psychedelic therapy (which I would try if I could find an undergound provider). I have seen therapists with various specializations and backgrounds and usually stick with someone for at least 2 years before moving on. (Have also tried SSRIs, mood stabilizers, and anti-psychotics in terms of meds).

At this point I'm feeling a bit like a lost cause, but like I said I'm trying to determine what therapy can even do/what is in the realm of possibility - is it reasonable to expect it to reduce my suicidal thoughts when I experience a crisis or personal loss?

posted by CancerSucks to Health & Fitness (7 answers total)

I can only tell you what happened for me.

Depressive episodes (suicidal ideation, etc.) started in my early twenties. In my late twenties I started therapy and between that and medication I sort of got a handle on it. However, medication stopped working regularly and for the next ten years my life continued to be dotted by depressive episodes.

However, in my late thirties a chance comment I made to a psychiatrist clued us both in that I was in fact misdiagnosed. I'm Bipolar II. It took us two or three years to find the right combination of drugs with a tolerable set of side effects, but I have been stable for ten years now. My emotions are within reasonable boundaries -- for example, when I'm depressed I get sulky and I overeat but there is maybe just a whisper of suicidal ideation and I think that's just habit.

So, yeah. It took me roughly twenty years of futzing around before I found a solution that works for me. I can't tell you if that's a reasonable expectation for you, but the possibility exists.
posted by Tell Me No Lies at 8:54 PM on June 17, 2021 [4 favorites]

This stuck out to me:
"The episodes never come out of nowhere; they're always triggered by the exact same type of external circumstance (interpersonal loss/grief or relational trauma)."

It sounds like you've experienced specific traumas and you should try therapy focused on processing those before you assume this is your life sentence. You're working hard on the cognition side of your depression and grief (thoughts) - DBT and CBT and many forms of psychotherapy are all about changing cognition.

The only thing I see mostly missing in the list of things you've tried is a somatic focused therapy that processes trauma from the bottom up - that means dealing with your body and nervous system first, rather than thoughts.

EMDR is kind of a somatic therapy, but it isn't the only one, so I would encourage you to try others and see if they help you deal with the external circumstances you find triggering. I think it is reasonable to expect somatic therapy to help reduce the spiral into suicidal thoughts that happens when you are triggered. You might look into somatic experiencing, sensorimotor psychotherapy, or some forms of bodywork and yoga. Basically, if you can regulate your nervous system's response to the trigger, the sensations won't be so bad that it throws you into an acute episode of wanting to die, and you will feel like you have some space to work with your feelings before they get to a crisis level.

Also, if you haven't done this already, rule out physiological causes, get a good check up done. Deficiencies in various nutrients like magnesium, B vitamins/iron, vitamin D, zinc, omega 3s, etc. can contribute to problems with mood regulation. Head trauma also increases risk for mood disorders and suicidal ideation, so if you've been hit in the head or had a bad case of whiplash look into neurofeedback to help with that. Gut health also has a lot to do with mood regulation if you happen to have any IBS like symptoms. Functional medicine is a speciality that can help you work with all of this in a holistic way, although it can be tricky to find functional med MDs that work with insurance depending where you are. I had a combination of these things and finally improving them helped me a lot with depression so I like to recommend them to others as something to consider. IANAD, TINMA.

imo i don't think you have an intractable mental health condition.
posted by zdravo at 9:55 PM on June 17, 2021 [9 favorites]

I hope this isn’t patronizing at all but I used to feel very skeptical about dietary changes making a difference to mental health. But a few years ago I started having chronic migraine and now I’m on a migraine diet and I’ve felt a big improvement in how I feel. Migraine definitely impacts my mood and anxiety levels and it’s strange to see that cutting out certain foods has improved the migraines and therefore improved my mood and anxiety. I’m also researching fecal transplant. Gross, I know, but there is a lot of interesting info out there. Anyway, it sounds to me like you’re having a big brain reaction to stressful events and those were a couple things that you hadn’t mentioned trying yet.
posted by pairofshades at 1:26 AM on June 18, 2021 [1 favorite]

Have you ever been assessed for a dissociative disorder?
posted by Merricat Blackwood at 6:14 AM on June 18, 2021

I guess just to expand on my question, above: if I were doing everything my therapists asked of me but not seeing any changes, I would consider the possibility of a misdiagnosis. My understanding is that dissociative disorders are often misdiagnosed as mood disorders, and it is common for people suffering from them to spend years in the mental health system being treated for issues that they don’t actually have. Given that trauma seems to be an important part of your story, and the dissociative disorders are essentially a form of PTSD, I would consider being assessed for them by someone with expertise in the field.
posted by Merricat Blackwood at 6:20 AM on June 18, 2021 [2 favorites]

I have tried … everything but psychedelic therapy (which I would try if I could find an undergound provider)

I think from past asks that you’re in the Boston area? If so, you can find any number of above-ground providers by searching for “ketamine therapy Boston.”
posted by slkinsey at 6:38 AM on June 18, 2021 [2 favorites]

I also wonder if you have been misdiagnosed. My symptoms were like yours (though it never got to hospitalization) and for the longest time I was treated as if I had major depression. Then I got a new psychiatrist who was up on the latest research into mood disorders and I was diagnosed Bipolar II. Until relatively recently it was thought that one had to have manic episodes in order to be bipolar. But there is more evidence that these downward swings can occur without the accompanying upwards and the disorder should be treated the same way bipolar is (though there's less concern about meds like Wellbutrin triggering a manic episode). This means different medication regimens (for example, Lexapro is appropriate for major depression but can make bipolar worse) and possibly different types of therapy. Personally I did not get much out of therapy until I got the right meds. I don't know how many psychiatrists you've seen but I would look into a new one, especially if they are associated with psychiatric research like psychiatrists at clinics attached to universities. In my case I was actually properly diagnosed by a resident who was not even an independent psychiatrist yet, so if your psych ended up being a student I wouldn't let that deter you either.
posted by socks_for_all at 9:36 AM on June 18, 2021 [2 favorites]