Solving treatment resistant depression

About 60% of patients suffering from depression do not find any benefit from their first antidepressant. Up to 20% of patients find depression impossible to overcome even after 1 year. Assertive treatment of depression from the get go is essential to helping recover from depression.

Psychiatrists don’t have a shared definition of treatment resistant depression. However, most would agree that your depression may be treatment resistant if it has not resolved almost completely after adequate trials of at least 2 separate treatments.

You, with your doctor and/or therapist, must then consider the following strategies to beat it.

Confirm diagnosis. Make sure that your depression is not a phase of Bipolar disorder – it can be tricky, but must be ruled out. Co-occurring addiction, anxiety or other psychiatric illness should be diagnosed and treated. Psychiatric diagnosis still remains a subjective enterprise. Get a second opinion regarding your diagnosis. Even if you like your therapist or psychiatrist, and intend to get treatment from them forever and ever, get a second opinion from a different psychiatrist.

Follow treatment recommendations. Take your medicine as prescribed. Maintain your frequency of psychotherapy. These things take time to work. Don’t skip doses or sessions. And don’t give up on any treatment prematurely.

Optimizing medication. Your dose of antidepressant may need adjusting to get better results. Some antidepressants work better at higher doses. Others have a window of dosing in which they may work the best for you while having the fewest side-effects.

Switching medication. There are about 30 antidepressants belonging to about 8 classes available in the US. Even among patients who have had trials of multiple medicines, most have tried only 2-3 classes. Talk to your doctor about trying medicines from classes that you have not tried yet.

Adding a medication. If you have partial response to a given medicine, adding another medicine that is compatible with the first medicine may allow you to build on the effectiveness of the above medicine. Talk to your doctor about this. The medicine added could be another antidepressant, or a medication that is known to help antidepressants be more effective (e.g., T3, lithium).

Talk therapy (psychotherapy, counseling). If you are not already in psychotherapy, you must consider adding this to your treatment regimen. Psychotherapy typically does not work as quickly as medication, but tends to have lasting benefit. Ask for a referral to a therapist who treats using one of the consistently proven therapies in depression – interpersonal therapy or cognitive behavior therapy.

TMS (Transcranial Magnetic Stimulation). This is a treatment that involves repeatedly delivering very, very short magnetic pulses to the part of the brain that is most believed to be involved in depression. It was cleared in 2008 by the FDA as effective in those who have failed treatment with 1 adequate trial of an antidepressant. It has few side-effects, but carries with a minuscule risk of seizures. It is an outpatient treatment that does not require sedation or anesthesia.

Electroconvulsive therapy (a.k.a. electroshock therapy). This is probably the most effective treatment for depression, but to be effective it requires that a seizure (convulsion) be triggered. Therefore, it must be conducted in a hospital setting, using sedation and muscle relaxation. It may impair memory in a lasting manner in some patients.

Most importantly, choose treatment with a physician, psychiatrist or therapist who will systematically evaluate how any chosen treatment is working. He or she should also be willing to change the medication regimen if it does not work in adequate doses over a 3-month period.

Through all of this you must also:

Practice living well. Eat a balanced diet. Excercise some everyday (to the extent your body allows and your physician approves). Minimize smoking, drinking. Attempt to connect with loved ones frequently. None of this may be easy when you are depressed, but overcoming treatment resistance requires you to do your part to the extent that you can.

Dheeraj Raina is a psychiatrist who blogs at the Depression Clinic of Chicago.

Submit a guest post and be heard.

Comments are moderated before they are published. Please read the comment policy.

  • http://doctorstevenpark.com Steven Park. MD

    It’s a given that depression can cause sleep problems. But it’s also possible that poor sleep can cause depression-like symptoms. Not breathing well at night can lead to chronic deep sleep deprivation and change your brain biochemistry. Since so many people have undiagnosed obstructive sleep apnea, it’s safe to assume that a significant number of people on antidepressants actually have a sleep-breathing problem. If the patient has unrefreshing sleep and has a parent that snores heavily, at least consider screening for obstructive sleep apnea. We routinely screen for rare conditions that occur < 5% of the time. Knowing that about 1/4 of all men and 1/10 of all women have undiagnosed sleep apnea, we should routinely use screening questionnaires such as the STOP-BANG and Epworth. It's also important to remember that you can be young, thin, and not snore and have significant sleep apnea.

    http://doctorstevenpark.com

    • AA

      Dr. Park,

      Great points.

      Another issue to consider is that a fallout from being on antidepressants in spite of tapering slowly is insomnia.

      In briefly looking at your website, I couldn’t tell if you addressed that. If you don’t, you might consider looking into this and finding ways to help people who are dealing with this.

      Sadly, most doctors simply suggest another med with a shotgun approach that is ineffective. I have only heard of one who actually knew how to use them appropriately at very low doses. This guy was also familiar with using supplements.

      Anyway, knowing what I now know about them, I wouldn’t have touched them in a million years. Another post.

      • http://doctorstevenpark.com Steven Park. MD

        AA,

        In my experience, chronic insomnia and sleep-breathing problems go hand in hand. In fact, almost every chronic insomnia patient that I see has very narrow upper airways behind the tongue. Dr. Barry Krakow, a pioneering sleep/nightmare/PTSD researcher, showed that 70 to 80% of chronic insomniacs that are resistant to hypnotic treatment had significant obstructive sleep apnea. Here’s the link to his abstract: http://www.psychiatrist.com/pcc/abstracts/abstracts.asp?abstract=09m00873bro/09m00873bro.htm

        This is why whenever you treat sleep-breathng problems, insomnia almost always improves.

        http://doctorstevenpark.com

        • AA

          Uh, I am not clear how this relates to my point about insomnia from antidepressant withdrawal problems. Many people never had any problems whatsoever with insomnia prior to being on psych meds and then tapering off of them them.

          • http://doctorstevenpark.com Steven Park. MD

            AA,

            You’re right—sorry about the off-topic comment. It’s possible that common withdraw symptoms such as poor sleep, anxiety, and agitation may be misinterpreted as insomnia while tapering off of psychiatric medications. In my experience, younger adults with clinical depression usually have major sleep issues, and have at least one parent that snores heavily (and most likely has obstructive sleep apnea). They also prefer not to sleep on their backs. Studies have also shown that your risk of cardiovascular disease increases later in life if you have depression.

  • stargirl65

    I like your ideas but most of my patients do not want therapy as it is time consuming and expensive. I have tried to tell them that it is very helpful, but money and job issues are often part of the problem and adding a therapy committment can break the bank.

    Employers need to be more understanding. Many of my patients can barely make med checks as they are in fear of losing their jobs just coming to see me.

  • http://www.depressiondocs.com/blog Dheeraj Raina, MD

    Dr. Park…I agree. Treatment Resistant Depression (TRD) is treatment resistant because of many reasons, the most significant of which is either a misdiagnosis or the overlooking of a comorbid psychiatric or medical diagnosis that makes things worse. I do think about OSA in patients when evaluating them; in my patient population, however, I find that OSA is usually not a cause of depression, but a ‘worsener’ of it and makes it seem like TRD even when it isn’t. I write about this in our clinic’s guide to treatment resistant depression in a chapter called “Prozac does not cure Anemia”. Our guide is at http://depressiondocs.com/treatment-resistant-depression/free-guide/

    Still thank you for the suggestion regarding the STOP-Bang and the Epworth.

  • skeptikus

    Dear Dr. Raina,

    I don’ mean to be disrespectful, but given the low rate of success for depression treatments and given that most depressions go away with time–have you ever considered that you are not really treating anything? A conclusion supported by the innumerable studies showing that placebos work just as well for mild/ medium depression as yr phamaceuticals . . . .

    In other words, do you people just apply the cures you learned–or do you have the courage to question whether your whole approach is bunk.

    Given psychiatry’s rather feeble record (e.g., Freud), shouldn’t you be open to that possibility.

  • http://depressiondocs.com/blog Dheeraj Raina

    Skeptikus…we completely agree on the matter of antidepressants not being the answer for everyone with every kind and severity of depression. Their benefit/risk must be deliberately weighed before prescribing them to any person.

    Nevertheless, I cannot, in good conscience, agree with the idea of leaving depression take it’s course. Left on it’s own, each major depressive episode will be time-limited, ending in 9 months to 2 years. And recurring within as little as 6 months. I cannot imagine not treating a person’s depression with every clinically appropriate and evidence-based means available and letting them and their family suffer for 2 years, and longer if recurrences just morph into almost continuous multi-year episodes, as often happens with untreated depression. Not to mention the risk of suicide.

    Each major depressive episode may be self-limited, if long, but Major Depressive Disorder is a chronic illness with relapses and recurrences, and carries significant morbidity and mortality risk. Slightly over 30,000 people die every year in the US by their own hands (that we know of) and over 90% of them are in a Major Depressive episode. As a comparison, less than 20,000 die by homicide.

    Lastly, I don’t think Psychiatry’s record is feeble. It is an amazingly complex and challenging science and art. Though today, looking through the ‘retrospectroscope’, we may accuse Freud (and Jung, Kohut, Kernberg, Skinner, Beck) of making mistakes and overselling his theories but no one can deny the impact he has had as being a pioneer in trying to understand the mind, trying to be there with patients, listening to the said and the unsaid. All pioneers, in any walk of life, can be similarly, and legitimately critiqued.

    None the less, since Freud, psychiatry has continued to follow the path of science, in the sense that, each successive theory of the mind has been challenged, so that we now have a range of treatment options available for patients from various kinds of therapies to various kinds of medications. We also have the knowledge and wisdom to know not to make the mistake of the pioneers; we know that no particular theory of the mind explains every person, in every instance, and that no particular treatment will help every person, in every instance.

    That’s a long way to have come since Freud, but to give credit where it is due, he gave this journey of understanding the mind a very strong push.

    • AA

      Dr. Raina,

      As one who experienced horrific side effects from being on psych meds, I have to agree with Skeptikus.

      I keep reading claims from psychiatrists that say antidepressants work but no one can give me links to any studies that prove they even work for a year. The Star D study, which was supposed to be the gold standard, turned out to be very faulty.

      I did want to address the point you make about recurrence. Many people are tapered way too quickly on psych meds and as a result, what is really a withdrawal symptom is falsely pegged as evidence the person needs the drug.

      I honestly think as a result, that gives very inaccurate statistics as far as depression recurring.

  • skeptikus

    Dear Dr. Raina,

    Thank you for your thoughtful answer. It reflects a compassionate, kind and committed professional. But, again respectfully, I think you’re deluded. We won’t settle these matters on an internet forum but I wish you’d consider the following assumptions you make:

    1. Psychiatry is science. You say: “None the less, since Freud, psychiatry has continued to follow the path of science, in the sense that, each successive theory of the mind has been challenged”

    Freud? science? Umm . . . are his experiments reproduceable? Are they falsifiable? If not, they ain’t science. They’re quackery. And, quackery does more harm than good. Is the world a better place because millions of people spent years in useless analysis, Freudians blamed autism on insufficient maternal love, homosexuality viewed as an illness? First do no harm, indeed!

    This excesses resulted from professionals, like you, who presumed to treat using their medical judgment rather than science. And yet you continue in your blindness. You say:
    “We also have the knowledge and wisdom to know not to make the mistake of the pioneers; we know that no particular theory of the mind explains every person, in every instance, and that no particular treatment will help every person, in every instance.”

    If everyone is different, then you are NOT applying scientific trues, which by definition, are universally applicable. You are not applying evidence based treatment because you can’t define the parameters of any study or experiment.

    In short, you’re being just like Freud . . . . and did he do any one patient any good? I say no.

    • http://depressiondocs.com/blog Dheeraj Raina

      Indeed, our differences will not be resolved here.

      If you think about it, there is no universal cure in medicine for anything – except for infectious diseases for which treatments kill bugs at least for brief period before the bugs develop resistance in the next group of victims. By this standard, nothing about medicine is scientific.

      In my view, Freud’s greatest contribution was not his theory of the mind – he saw too few patients to come up with a universally applicable one. Instead, it was this idea that if we spend time really listening to patients suffering from emotional turmoil, if we pay attention to what they say and leave unsaid, if we think about how the two might be connected, if we try to understand mental mechanisms by which wishes, dreams and fears underlie emotional symptoms, we might be able to alleviate some forms of mental suffering.

      Almost every kind of psychotherapy that came since, including CBT, which has proven it’s mettle in many studies of depression and anxiety, ultimately accepts this way of thinking about victims of mental illness. The theory of the mind, i.e. how to think about the emotional mechanisms that make symptoms, is different from one kind of therapy to another, but the essence of the underlying approach is the same.

      We will probably continue to disagree, which is okay. I truly appreciate you taking the time to comment on my post.

  • AA

    Dr. Park,

    Thanks for the clarification. But I still think you’re missing my point.

    “”You’re right—sorry about the off-topic comment. It’s possible that common withdraw symptoms such as poor sleep, anxiety, and agitation may be misinterpreted as insomnia while tapering off of psychiatric medications. In my experience, younger adults with clinical depression usually have major sleep issues, and have at least one parent that snores heavily (and most likely has obstructive sleep apnea). They also prefer not to sleep on their backs. Studies have also shown that your risk of cardiovascular disease increases later in life if you have depression.”

    Withdrawal symptoms such as insomnia from years of AD use are due to antidepressants greatly disrupting the sleep architecture. Anxiety, depression, and agitation may result but those are secondary issues to the insomnia resulting from med withdrawal.

    I fear with your interpretation that the primary issue will be overlooked resulting in inappropriate treatment and someone being falsely pegged as having a mental illness.

    Uh, I keep reading the claim that depression causes heart failure but do you have a link to an accessible study proving this? It would help too if the researchers didn’t have drug money conflicts.

    Sorry I am a little skeptical since everything known to mankind seems to be linked to depression.

  • skeptikus

    Dear Dr. Raina,

    Thank you for your civil response. We will not agree, I’m afraid. But, I do take exception to this statement:

    “Almost every kind of psychotherapy that came since, including CBT, which has proven it’s mettle in many studies of depression and anxiety, ultimately accepts this way of thinking about victims of mental illnes.”

    Cognitive behavior therapy was pioneered by psychologists, not doctors, who resisted it. I agree CBT has helped people–and it has done so because psychologists accepted the strictures of the scientific method. Doctors, who as your post so richly illustrates, continue to resist it–to the peril and misery of so many.

    • http://depressiondocs.com Dheeraj Raina

      I am fine with agreeing to disagree. But I sincerely hope you are not confusing my blog post above with someone else’s. This is what I wrote above…”If you are not already in psychotherapy, you must consider adding this to your treatment regimen. Psychotherapy typically does not work as quickly as medication, but tends to have lasting benefit. Ask for a referral to a therapist who treats using one of the consistently proven therapies in depression – interpersonal therapy or cognitive behavior therapy.”

  • Donna Carrillo Lopez

    It is critical that patients have a regular exercise routine that should be somewhat diversified to maintain motivation and reduce motivational burn-out. Exercise stimulates enkephalins and endorphins and probably gabanergic responses on different spinothalamic/corticospinal and other nervous system tracts. Someone once stated that everything the body needs is already in the physiologic composition ready to be accessed with the right stimulus/response. Cognitive behavioral therapy and exercise as well as expertise in western herbs might well be the tools for efficacy, safety and effectiveness in depression as well as in insomnia. Just like a lake that ceases vigorous movement, stagnation can create pathology. Keep your patients adequately moving…this is the beginning to the miracle of the healing inner locus of control for all human beings.

    • http://depressiondocs.com/blog Dheeraj Raina

      Donna,
      You are absolutely right about the importance of excercise in managing depression. I think you might find the articles we have on our home blog (http://depressiondocs.com/blog) about the evidence regarding the role of SAM-e, fish oil and light therapy in the treatment of depression. We will soon be doing an article about the evidence-based recommendations regarding the role of exercise in depression treatment.

Most Popular