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When Medication Isn’t Helping Your Depression
As many people know all too well, clinical depressions do not always improve after the first attempt at treatment. One in three people with depressions (I’ll explain the plural in a bit) find they have not gotten back to “normal” even after four different courses of standard treatment.
Depression is considered “treatment-resistant” if symptoms have not improved after two or more courses of well-established treatments of a sufficient dose and length of time, whether those treatments are evidence-based medications, psychotherapy, or other therapies that have been proven effective.
That “or more” can be problematic. The longer your depression persists, the greater the risk of financial costs, job loss, family stress, marital problems, and even possible brain changes. That’s why it’s a good idea to discuss a diagnosis of treatment-resistant depression with your practitioner after two failures of treatment. The earlier you address it, the better.
There are a number of reasons why your depression might not respond to a particular treatment. For one thing, there is no single type of depression; there are multiple causes. That is why it is actually most accurate to use the plural term (depressions), and why “one-size treatment” will never fit all.
For another, effective treatments that are not followed cannot work. If a person is not taking the doses of medication as prescribed or doesn’t stick with the recommended treatment, a depressive episode should not be considered “resistant.”
If my depression resists treatment, what are my options?
It’s easy to get discouraged when the treatments you’ve tried haven’t helped you reach recovery. (And remember: Better but not well is not good enough.) Above all, don’t give up hope. Here are some things to consider.
- Simply switching from antidepressant to antidepressant may not be useful. As shown in the STAR*D study, the largest American study of treatment-resistant depression, more proactive steps appear to be needed once treatment resistance has developed.
- Returning to a medication that worked in a previous depressive episode may be more effective than switching to a new one. If it doesn’t work as promptly as before, remember that it may do the job at a (safe) higher dosage taken for a longer time period.
- Give treatments a chance to work. While the typical time frame for good response to a medication is stated as four to six weeks, for many people it can take 8 to 12 weeks to see improvement.
- If medications or psychotherapy have been ineffective on their own, consider trying them in combination. Medications plus cognitive behavioral therapy, interpersonal therapy or dialectical behavior therapy traditionally outperform either treatment used alone.
- Augmentation of your antidepressant with an adjunct or “add-on” medication, often an atypical antipsychotic, may be helpful if you’ve had partial response to a treatment.
- Other “augmentation” agents that pro-vide benefits for some people include nutrition supplements such as Vitamin D, Omega 3, and folate.
- Electroconvulsive therapy (ECT), commonly known as shock therapy, has long been stigmatized in popular culture. It is an extremely safe procedure, acts rapidly, can be life-saving, and is sometimes the only effective treatment. It does produce memory problems for some.
- Other “neurostimulation” treatments, such as Transcranial Magnetic Stimulation (TMS), are coming into wider use. TMS is a non-invasive procedure that typically can be delivered in about an hour each day in an office setting.
Once you find something that works, don’t change a thing. Just as someone with diabetes requires ongoing treatment, most people who have developed chronic, recurring depression need to continue treatment indefinitely.
By John F. Greden, MD. Dr. Greden has been practicing psychiatry for 35 years. His clinical specialties include treatment-resistant depression and maintenance of wellness. The Rachel Upjohn Professor of Psychiatry and Clinical Neurosciences at the University of Michael Medical School, he is also the founder and executive director of the UM Comprehensive Depression Center (depressioncenter.org) and the founding chair of the National Network of Depression Centers.
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Dr. Irving Kirsch, a professor at The University of Hull, has caused a stir lately with a body of research suggesting that SSRIs, the most common class of antidepressant, are no better than placebos. (Here is a 60-Minutes story about his findings.) Of course, for every SSRI skeptic there are any number of evangelists who swear by the drugs.
Personally, I’m undecided. I’ve seen SSRIs aggravate depression by muting happy emotions and adding unpleasant side-effects, while offering no measurable antidepressant effect. But I have also seen them help. In rare cases, they have been a godsend.
For anyone considering antidepressants, I would humbly suggest that the question, do antidepressants work, is the wrong question. The more relevant and pragmatic question is this: might antidepressants be helpful in my particular case?
The SSRI debate is useful in general, but it is mostly irrelevant to individual cases. It’s a bit like debating the effectiveness of transmission replacements for cars. Sometimes a new transmission fixes a car, sometimes it doesn’t. It depends on the problem.
If I found a mechanic who insisted on rebuilding every transmission (or who reflexively opposed it) I would find a new mechanic, pronto. I wouldn’t settle for one who failed to define the problem before tearing into my car. Yet that is often what is expected of patients who seek treatment for depression. Describe your symptoms – quickly! – and don’t question my treatment.
It seems to me that our central nervous systems should get at least as much respect as our cars. Of the many times that I have witnessed the failure of an antidepressant, there has been a corresponding misapplication of the drug. The correlation is difficult to ignore.
But don’t take my word for it. There is compelling research suggesting that antidepressants are routinely misused in Western countries. In a rather conservative study, Jureidini and Tonkin (2006) found that many prescriptions (one third or more, depending on the measure and the population) fell outside clinical indications, were given in excessive doses, or were prescribed for far longer than they should have been.
According to another study, only about one-third of patients experience relief after taking an antidepressant for a sufficient period of time (Cascade, Kalali, and Blier, 2007). That’s an exceptionally low number, and I suspect that has more to do with poor diagnosis than the effectiveness of the medication.
Antidepressants may be the first and best option in cases of severe depression. But in mild or moderate cases – which are the vast majority – behavioral interventions work better. Addressing the problems that lie behind depression is often more effective and longer lasting than medication (Dobson et al. 2008).
(Ironically, Jureidini and Tonkin also found that antidepressants are under-prescribed among the seriously depressed who could most benefit from them. They noted that fewer than 25 percent of US, Canadian, and European patients meeting criteria for major depression receive proper medication management.)
Antidepressants appear to be helpful in severe cases but they are probably useless and potentially harmful when they are incorrectly prescribed in less severe cases. I believe that anyone considering SSRIs should first answer these four questions, with the help of a qualified clinician:
- How severe is the depression? There are a number of depression inventories to help answer this question. If the symptoms are in the mild to moderate range, SSRIs are probably an inappropriate intervention.
- Is the depression most likely a result of circumstances or lifestyle choices that will remain unaffected by medication? If so, pills may blunt moods but they won’t fix the problem.
- Have physical problems been ruled out? Depression can be secondary to thyroid problems, low testosterone levels, nutritional deficiencies, sleep difficulties, and other physical problems. SSRIs fix none of these.
- Have healthier interventions failed? Making tough decisions about exercise, diet, sleep, alcohol use, and other lifestyle choices should be the first order of business in cases of mild to moderate depression. Physical exercise alone is as effective as any antidepressant in most cases (it is the benign cure-all that SSRIs wish they could be), and cognitive behavioral therapy is an excellent response to circumstances or lifestyle choices that contribute to depression.
SSRIs should only be taken with considerable deliberation and a solid understanding of the problem at hand. Despite their benign image, they are the furthest thing from harmless happy pills. They come with side effects, and there is evidence that they can have serious, long-term effects on the central nervous system. If SSRI’s are the right answer for you, then by all means, use them. But please take the time to properly define the problem first.
I realize that it is an investment of time and money, and I know that depression deprives a person of gung-ho initiative. It might be simpler to skip the process and take the pills, but we only get one brain each. Taking time to define the problem could prevent years of wasted effort and needless suffering.
Dr. Shawn Smith is a psychologist in Denver and the author of The User’s Guide to the Human Mind: Why Our Brains Make Us Unhappy, Anxious, and Neurotic and What We Can Do about It.
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