Treatment-resistant depression can feel hopeless and frustrating, but there are good options for treatment.
Depression is one of the rr □ v 8 v & © tl @ ns, affecting 5% to 20% of people at some point in their lives. For some, therapy and medication work \Nell, and symptoms are kept under control. For others, treating depression gets a little trickier.
Treatment-resistant depression (TRD) means that your symptoms have not responded to at least t\NO different antidepressants. In addition, these medications must have been tried for at least 6-8 weeks each before a diagnosis of TRD can be given. Most psychiatric providers consider the following antidepressants first-line options for depression:
• SSRls (serotonin reuptake inhibitors), such as sertraline (Zoloft), fluoxetine (Prozac), escitalopram (Lexapro), and paroxetine (Paxil)
• SNRls (serotonin and norepinephrine reuptake inhibitors), such as duloxetine (Cymbalta) and venlafaxine (Effexor)
• Bupropion (Wellbutrin)
• Mirtazapine (Remeron)
TRD can develop in those who initially did respond to antidepressants and is characterized by the same symptoms those with depression struggle with, including disturbances in mood, sleep, energy, and appetite. However, symptoms are often more severe in TRD, depressive episodes last longer, and there is a higher number of lifetime depressive episodes.
What causes treatment-resistant depression, and who is at risk of developing it?
Although we don’t know the exact cause, TRD seems to be multifactorial, involving genetics, brain chemistry, and chronic stress. Some other risk factors for developing TRD include cardiovascular disease, cerebrovascular disease, autoimmune diseases, and thyroid disease. Your physician will also review your medications, as some supplements, over-the-counter medications, and non-psychiatric medications can actually worsen depression or interact with your antidepressants, decreasing their effectiveness. Your physician will also review how regularly you take your medications, whether you use any potentially harmful substances, and whether you have chronic pain, which can all contribute to TRD. Other psychiatric conditions can mimic TRD (e.g. ADHD, bipolar depression, or personality disorders), but require a different approach to treatment.
While TRD is generally not preventable, there are evidence-based actions one can take to better manage stress that translate to a lower risk of developing TRD. These include exercising regularly, eating a balanced diet, avoiding alcohol, getting enough sleep, practicing mindfulness, meditating, practicing yoga, and staying connected to one’s support system.
How can TRD be treated?
Having TRD does not mean that you are out of options when it comes to treating your depression. Despite its name, there are several options available, including other medications. Some of the first steps may include your psychiatric provider:
• Giving your current medications more time to work
• Increasing the dose of a first-line antidepressant (e.g. an SSRI, SNRI, bupropion, or mirtazapine}
• Adding an antidepressant from a different class to your original medication
• Encouraging you to see someone for therapy if you are not already doing so
• Considering other medications, such as those FDA-approved for TRD
(aripiprazole (Abilify), brexpiprazole (Rexulti), quetiapine (Seroquel), olanzapine (Zyprexa), or esketamine nasal spray (Spravato)), or others such as lithium, tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOls), or pramipexole (Mirapex)
Don’t lose hope if medication changes have not proven enough to get your depressive symptoms under control. The FDA has determined that the following treatments can be helpful for some people with TRD:
• Transcranial magnetic stimulation (TMS): a noninvasive treatment that uses a magnetic coil to influence and enhance your brain’s baseline electrical activity.
• Electroconvulsive therapy (ECT): a medical procedure that involves passing a small electric current through the brain causing a short, controlled seizure. This safe and effective treatment can stimulate nerve cells and improve depression, and requires anesthesia for comfort.
• Deep brain stimulation (DBS): a medical procedure that involves delivering a mild electrical current directly to a specific part of the brain.
• Vagal nerve stimulation (VNS): a medical procedure that involves implanting a device that will send regular pulses of electricity to your brainstem through the vagus nerve in your neck
Research involving psilocybin, a psychedelic compound isolated from hallucinogenic mushrooms, has shown initial promise, but is not yet FDA-approved.
If you or someone you know is experiencing TRD and wants to discuss treatment with TMS, please call our office at 860-846-7137 to speak with one of our doctors.
The information provided on this blog is intended for general informational purposes only and should not be considered as medical advice. It is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. The authors and publishers of this blog are not responsible for any errors or omissions in the content or for any outcomes resulting from the use of the information provided herein. The views and opinions expressed on this blog are solely those of the author and do not necessarily reflect the official policy or position of the company.