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.

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