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.