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.
4 thoughts on “When Medication Isn’t Helping Your Depression”
I would add food choices and exercise as viable options for dealing with treatment resistant depression. I believe that they have been effective in reducing some of the worst effects of major depression. While not a cure, improving the quality of the food you eat and physical movement are both going to help both your body and mind. Have you experimented with diet and exercise for depression, I am interested in your comments. Thank you for the article on this important topic which I do not see covered much in the news. Richard http://hashimashi.com
Rich, thanks for your great comment. I have experienced on and off with exercise – the more the better, but I am not very consistent with it. Diet has been tougher. Dan
Years ago I used meds like lexapro, effexor, neurontin and seroquel. I gave up after many years of waking up in sweats, insomnia, nightmares, hallucinations (fortunately just one of my reflection speaking to me which was scary enough) and suicidal ideation which I never had before). I was so freaked out I stopped most of my meds cold turkey. Unfortunately stopping the meds did not change the consequences of the time that I had been on them, divorce, career loss and damaging important relationships that I do not see any possibility of recovery. My psychotherapist recommended exploring writing, food and exercise if I could not use the meds. The good news is that I found that the same food plan so to speak, basically real food as opposed to processed, focus on vegetables, fruits, legumes, nuts, good quality protein, organic eggs for example and grass fed meat without hormones, made a difference not only in my ideation but also physically. I know diet is tougher because when we are in the throes of processed food, it is really difficult to break the cycle of starving most of the day and then consuming too much processed food at night. I cannot say which came first, but losing 75lbs and feeling some extent of relief from deep depression was welcome. I still deal with certain other aspects, but at least im not calling hotlines with very negative thoughts. I think there is a link between the health of our body and our mind, and for example when I began to train with weights, the more my testosterone increased from lifting weights and having less fat on my frame (which will reduce estrogen), the better that I felt. That is mainly what I am interested in researching, how to deal with treatment resistant depression via food and exercise when meds are not the answer. I zero in on testosterone because about ten months after changing from junk food to real food and from sitting and moping to walking and weight lifting I experienced much less ideation, physical changes and I remember my doc saying that my testosterone had more than doubled, so it might be something to explore for any of us when medications are not working, at least before electroconvulsive shock treatment. Here is a short post on testosterone: http://hashimashi.com/what-does-testosterone-do/ . Thanks again for having this site, I had no clue that this exists and in fact, I do know another person who can really get some benefit from your site so I will pass it on to him. Rich
Hello friend. I just read your post about treatment resistant clinical depression. I understand that depression can be tough, and can weigh people down in many ways. I believe that reaching out for help is a strong thing to do. If I may ask, do you believe in God? God is an ever present help in times of need, he wants us to be truly happy. God has the power to instill happiness even in the life of someone whose depression is resistant to treatments. If you can keep an open mind, here is something that you should try: Find a quiet space free from distractions, imagine that Jesus is in front of you, talk to him the way you will with a close friend, tell him how you feel. Beware of sudden distractions when you pray, this is a trick the devil uses to stop us from having focused prayers. You might also get the feeling that God is not there or that you are simply wasting your time, this is another trick that the devil uses to discourage us from prayers. Be focused and tell the lord how you feel. Jesus is there with you and he cares for you, so invite him into your life and ask him to pour out his blessings. When you get the answers to your prayers, do not forget to thank God. Also try to maintain a relationship with him, keep telling him how you feel, keep thanking him and finding out about him. This way he can remain in your life and continue to work his miracles. Good luck and God bless.