Synopsis: Many people with longstanding depression believe that they have tried every treatment out there. A detailed review of their history often reveals that they are mistaken and that there are several strategies that they have never tried. This article addresses what information is needed to make a well-informed decision about what treatment to try next and how a history of past treatments combined with a strategic, methodical approach can open up options to newer and potentially more effective treatments.
BY LEN LANTZ, MD, author of unJoy / 9.28.20; No. 36 / 8 min read
Disclaimer: Yes, I am a physician, but I’m not your doctor and this article does not create a doctor-patient relationship. This article is for educational purposes and should not be seen as medical advice. You should consult with your physician before you rely on this information. This post also contains affiliate links. Please click this LINK for the full disclaimer.
Record keeping is worth it
For most people, keeping an updated list of every medication they have ever tried for depression is the most boring and tedious thing in the world, especially if they are already depressed. It can also be really hard to go back years or decades and try to figure out the names of all the therapists you saw and medications you tried because it may be hard to track down old records.
You might think that your medical record will always be there, but unfortunately, that is not always the case. All states have laws that require medical records for adults from the past 5-10 years to be available (there are a few exceptions in certain states) and for medical records to be available for a slightly longer period of time for children. Federal law requires a similar range for medical record retention for certain health insurance plans.
Most people are disturbed to learn that their six-year-old medical records might be gone. This can create a huge problem for patients, especially because insurance companies, in order to cover some of the more expensive treatments, often require evidence that a less expensive medication/intervention was previously tried and failed. Even if you have used the same pharmacy for decades, you might have a very hard time getting your past prescription records that are more than a year old. Pharmacies, hospitals and clinics update their software frequently, and when they do this, there can be problems accessing older records that were created by software that is now obsolete or has been deleted.
If you can’t rely on the medical system for your records, what can you do?
There are options. Most of the strategies involve active effort on your part. You have a right to access your medical records and can request copies. There is usually a cost with requesting large amounts of medical records because the records are owned by the hospital, doctor, pharmacy or clinic and staff members must collect the records for you.
Another option is to keep your own summary of treatment. This is not a bad idea, as most electronic medical records systems in the US do not communicate with each other. Until that changes in our country, you might be the best person to keep track of your past and current medical treatments.
What information should you record?
The types of information that can be helpful in treating your depression are extensive and might require a lot of effort to collect. Please don’t get demoralized when you do this. You might feel like giving up when you look at your list of failed treatments. A skilled psychiatrist might look at the same list and wonder why you have not tried a dozen other strategies. Information that can be helpful includes:
A detailed list of medications
Therapists and types of therapy
Assessments and evaluations performed
Hospitalizations and placements
Interventions like transcranial magnetic stimulation TMS) therapy, electroconvulsive therapy (ECT) and ketamine/esketamine
Other strategies you have tried or are currently utilizing
I have created a “Record of Past Psychiatric Treatment” form to show the types of information that are most helpful and to make it easy for you to keep all of your information in one place. Click HERE to download a pdf of the form for free.
Why is a list of past psychiatric treatment helpful?
In the hands of a knowledgeable psychiatrist, a record of past treatment yields critical information. Good psychiatric care first starts with an accurate diagnosis, and sometimes a clear record of the failure of multiple appropriate medications leads to a review and revision of a diagnosis, resulting in more effective treatment. Additionally, having access to all your past treatments for depression can help you and your doctor to:
Return to the treatment that worked best: Some people will say, “No, I never did well. I never felt better,” when that is simply not true. It’s not their fault that they are remembering incorrectly. A depressed person can forget what worked and that they were ever happy. I have had several patients who were in full remission of depression for years and, at some point, transferred their treatment to primary care or did not return for follow-up. Among the patients who later returned to my care, some returned on a completely different combination of medications, and they returned to my care because they were again severely depressed. These patients were surprised to learn that they did well on a past medication, and as we transitioned them back to their previous, effective medication, they were again able to achieve full freedom from depression.
Discover errors in medication treatment: A quick review of past medication trials that shows doses, durations and responses can reveal oversights in treatment. The medication list can show errors or opportunities in treatment, such as:
A medication trial was too short
A medication trial was prescribed at a subtherapeutic dose or the dosing was not increased through the entire therapeutic range
There was a pattern of poor medication adherence (skipping too many doses)
Medication selection may have been narrow (a medication from a different antidepressant category may have been ignored)
Medication selection may have been wrong, such as the use of only mood-stabilizing medications to treat major depressive disorder
There may have been no medication combination strategies or use of augmenting medications
Prevent a retrial of a medication that didn’t work or led to an adverse reaction: Some people have gotten quite sick from a past medication and cannot remember or find the name of the medication. Having a list of past medication trials and responses or side effects to each medication can prevent fruitlessly or painfully repeating the same failed strategy.
Discover diagnostic errors: A pattern of several different antidepressants making you manic, destabilizing your mood or simply making you worse should lead your doctor to consider the possibility of a diagnosis other than major depressive disorder.
Address treatment non-adherence: Some people take antidepressant medications irregularly or stop the medication on their own for periods of time. This greatly undermines the benefits of an antidepressant and leads to confusion about the effectiveness of the medication.
Uncover non-medical interventions that you didn’t know were effective: Many people with depression are quite surprised to learn of the tremendous, positive impact that evidence-based psychotherapy, exercise and behavioral activation strategies can have on depression.
Obtain pharmacogenetic testing: Some people experience significant side effects even on low doses of psychiatric medication. Others might see a benefit with medications, only to lose their improvement shortly after starting a medication or after each dosage increase. If this pattern emerges, your doctor might order genetic testing to determine how your body processes the medications (see Len’s article, “Genetic Testing for Psychiatric Medications”).
Try a treatment that you considered to be less-preferred: Sometimes people avoid certain treatments that have excellent evidence for helping but may have more side effects. Examples might include lithium (risk to kidneys and thyroid), Wellbutrin (risk of seizure and may worsen anxiety) and electroconvulsive therapy (involves the use of anesthesia, generates temporary seizures and negatively impacts memory). Reviewing a list of past strategies that were ineffective might help convince you and your doctor to try a less-preferred treatment or medication augmentation strategy.
Document the severity of the illness to show medical necessity for more expensive treatments: Newer psychiatric medications are more expensive, as there are no generic versions available. Also, some psychiatric treatments, such as intranasal esketamine, TMS therapy and ECT, require many treatments in a single course of care, which increases the cost. Most insurance companies have a prior authorization process to approve more costly treatments, and one of the requirements is to have tried and failed less expensive treatments, such as generic antidepressants. Having a detailed list of past medication trials is usually required to gain access to more expensive treatments, including brand-name medications.
Deal with avoidance: Some people use every possible strategy, yet still struggle with depression. However, some people with treatment-resistant depression show a clear pattern of avoidance and continually skip doses of their medications and/or effective interventions such as psychotherapy, behavioral activation and exercise in the treatment of their depression. For more information on avoidance, please see my article, “What to Do When You Know Why You Are Depressed.”
A story about the benefits of keeping records
“Sally” was a 27-year-old elementary school teacher. She loved her job and was in a committed relationship but wasn’t ready to start a family. She had developed depression in college after experiencing sexual assault in her sophomore year. She developed PTSD from the rape and the trauma and depression set her back a year in her education.
She tried several antidepressants and, while she saw improvement in depression and anxiety, she felt like her emotions were blunted from antidepressants and she hated that the medications that were prescribed caused sexual dysfunction. Her PTSD improved a lot with treatment over the past several years, but she had generalized anxiety symptoms that she continued to work on in therapy. She decided to put together a list of all her past medications, therapists and strategies that she used to improve her depression and PTSD over time, and she brought it to her first meeting with a new psychiatrist.
The doctor expressed appreciation to Sally for spending the time organizing her past treatment history, as her past medical records were requested but only a few of the records were received. Sally and her new doctor talked about her diagnosis, current and past symptoms, her work in psychotherapy and her goals for her treatment. In addition to talking about non-medication strategies for targeting her depression and anxiety, they discussed her past experiences with antidepressants and what symptoms she hoped a new medication would help. After considering Sally’s specific circumstances, her doctor shared some ideas with her and said, “Well, I’m surprised that your previous doctors never added a low dose of Wellbutrin or Buspar to correct the sexual dysfunction that you had from the antidepressants you tried. They might not have known about those strategies or they might have avoided Wellbutrin because it has the possible effect of increasing anxiety. There are really several different strategies that we could pursue today.”
Sally ultimately decided to utilize Wellbutrin to treat her depression. She found that she was able to achieve remission from depression with the medication and it did not cause sexual dysfunction. The medication did increase her generalized anxiety but not her PTSD symptoms. She continued to work with her psychiatrist, who added a second medication to help her anxiety, which was then manageable with continued exercise and skills she learned in psychotherapy. Sally was happy with the improvement she had achieved for herself.
Accurate record-keeping can help you treat your depression and give you hope
If you believe that you have tried everything for your depression and that nothing works, you are not alone. However, putting together a comprehensive summary can help a skilled psychiatrist quickly spot gaps in your treatment and options that you didn’t know existed. Wouldn’t it be great if your doctor looked at your summary and was able to list 5 new options when you felt like you were at the end of the road? You also might see for yourself that there are free and effective strategies for depression that you are avoiding and decide to work with a skilled therapist to start dealing with your avoidance behaviors. Imagine your history as the key to unlocking more options. The records of your treatment exist because of your effort and they provide a reference point for you and your doctor on your journey toward wellness.
For further reading, check out:
Len’s article “A Plan for Stubborn Depression”
Len’s article “The Surprising Results of Exercise for Depression”
Len’s article “Acting on Anxiety – Knowing When to Confront It or Avoid It”
Len’s article “Behavioral Activation for Depression”
A Guide to Rational Living by Drs. Ellis and Harper (See Len’s Book Review)
Mind Over Mood, Second Edition: Change How You Feel by Changing the Way You Think by Drs. Dennis, Greenberger and Padesky (See Len’s Book Review)
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