Depression is a condition that is typically treated with medication, therapy, or both. It is often managed very well with the proper treatment, however, there are instances when depression does not respond fully or even partially to these common treatment options. This type of depression is considered treatment-resistant depression and it affects different people for different reasons.
Relief from the symptoms of depression is all about regaining a comfortable and vibrant quality of life. When someone is not getting the positive results from depression treatment, they are losing out on the ability to enjoy things they once loved. Spending quality time with friends and loved ones are important parts of a person’s overall well being, and long-term depression hinders one’s ability to feel valued and loved in such relationships. When depression treatments are not helping a person get back the energy and enthusiasm for living that they once had, it may be time to explore more treatment options.
Getting a person back to a point in their life where living is something to be looked forward to, instead of feeling like a chore, is one of the main goals of depression treatment. For those people who do not seem to respond as well to current treatments over a long period of time as they should, special consideration to this treatment-resistant depression may be needed.
What Is Treatment-Resistant Depression?
The clinical definition of treatment-resistant depression (TRD) is a term used in clinical psychiatry. It describes a person who has major depressive disorder who does not respond adequately to antidepressant therapy within a stated time frame. The definitions vary slightly and specifically refer to non-responsiveness to medication therapy, not psychological therapy. An insufficient response to treatment has historically been referred to as “no clinical response whatsoever.”
More health care professionals agree that if a full remission of symptoms is not achieved with typical treatment for depression, then the response to treatment is considered inadequate. Patients with treatment-resistant depression who do not respond to treatment are sometimes termed pseudo-resistant. Some factors should be considered before referring to someone as having treatment-resistant depression.
The following characteristics and behaviors may be present during the treatment of depression which does not automatically mean the patient is not responding to prescribed treatment:
- Those who stop treatment early. Antidepressants typically take up to 12 weeks before symptoms are relieved.
- Medication dose is not sufficient. Often, doctors will start with a low-dose medication and increase the dose as needed after a minimum of 6-8 weeks.
- Patients who are non-compliant. This refers to those who do not take the medication as directed.
- Patients who may be misdiagnosed with depression in the first place.
- A patient with a concurrent underlying psychiatric disorder.
What Is the Best Treatment for Treatment-Resistant Depression?
If you have tried traditional treatments for major depressive disorder and your symptoms are not abating, then you need to know the best treatment for treatment-resistant depression. Treatment-resistant depression is complex. There is no one, foolproof way to treat this condition. It takes patience, grace, and a lot of support from professionals who are experienced in managing this type of mental health disorder. The first three areas where the work will start are generally medication adjustment, talk therapy, and coping mechanisms.
Just because one antidepressant is not effective in alleviating depression symptoms, does not mean that no antidepressant will work. Often one of the first steps a physician will take is to try another medication in the same class to see if it is any more effective. The second step that may be taken, if two or more medications in the same class are ineffective, is that a physician may try another class of antidepressants.
For example, they may change from an SSRI to an MAOI. The two different classifications of medications affect brain chemistry from different angles. A third step is often needed if the first two options prove to be ineffective, and that is combining two different types of medications to achieve positive results. We will discuss alternatives to antidepressants later, in the event that none of these three options yields symptom relief.
The most effective type of psychotherapy for depression is talk therapy that includes cognitive-behavioral therapy (CBT).
The goals of cognitive-behavioral therapy are:
- Look at negative thoughts in a different way.
- Increase positive social interactions.
- Enhance problem-solving skills.
- Improve physical activity level.
- Address sleep patterns if needed.
Cognitive-behavioral therapy is performed individually or in a group setting. It is important to receive therapy from a professional so that you are held accountable. The multi-faceted approach of CBT is found to be very effective in treating depression.
Dealing with treatment-resistant depression is difficult and requires a lot of work that can become mentally and physically exhausting. Establishing good coping techniques will set you up for success. Take a look at these 4 tips to help you commit to your journey to recovery:
1. Stick to your plan.
This includes taking your medications as prescribed as well as attending therapy sessions as scheduled. Skipping meds or talk therapy may seem insignificant at the time, but not sticking to your plan can quickly throw you off track. As hard as it may be, hold yourself to a routine and follow it closely.
2. Reduce stressors in your day-to-day life.
Stress can come in all forms, including unhealthy relationships, a poor work environment, and financial stressors. Adopt a few stress management techniques to help you with this, such as journaling, yoga, regular massages, or meditation.
3. Avoid substance use.
Alcohol and drugs do not mix with antidepressant medications. Substance use will make symptoms of depression worse and lessen the effects of prescribed medications.
4. Take good care of yourself.
Self-care has never been more important. Being kind to yourself may seem difficult, especially when you are not feeling well, but prioritizing healthy eating habits, adequate sleep and regular exercise at all costs will help you more than you can imagine.
What Are Some Alternatives to Antidepressants?
If antidepressants have not been effective in treating your depression, there are alternatives. One substitute for antidepressants is the medication ketamine. This medication was originally used as an anesthetic. However, it has since been known to act as a pain reliever and a sedative. Additionally, it affects the part of the brain that deals with depression.
Ketamine for Depression
Ketamine can be a life-saving resource for those with major depression accompanied by suicidal thoughts. The effects of using this medication can be experienced immediately, which is an advantage over most medications that can take up to two months to work.
There are three types of ketamine:
1. Ketamine Injection
Ketamine is administered through an intramuscular injection in the arm.
2. Racemic ketamine
This is given as an IV infusion directly in the bloodstream.
3. Esketamine (also known as Spravato)
This type of ketamine is administered in a nasal spray.
Exactly how ketamine works as an effective treatment in depression is unclear. It’s suspected that it has something to do with the way it targets the NMDA receptors in the brain. It might also reduce areas of inflammation that are related to mood disorders.
Like all medications, there are potential side effects that should be reviewed before starting a new medication. They include high blood pressure, nausea and vomiting, perceptual disturbances, and, in rare cases, dissociation.
Spravato for Treatment-Resistant Depression
As mentioned, Spravato is also known as Esketamine, the nasal spray version of ketamine. Spravato is prescribed to adults with treatment-resistant depression and is used under the supervision of a healthcare provider. How much you take and how often you take it will be determined by your physician and should be followed exactly as recommended.
What Is the New Treatment for Depression?
Aside from antidepressants and drugs like ketamine, one of the newest treatments for depression is transcranial magnetic stimulation or TMS. This treatment is a non-invasive way to stimulate certain nerves in the brain to improve symptoms of depression. TMS is typically considered when other treatments for depression fail to be effective.
What to Expect With TMS Therapy for Treating Depression
With TMS therapy, your first treatment will take about an hour. Once it is determined where the best place is to put the magnets, you will be hooked up to the electromagnetic coil that will produce stimulating pulses. During this part, you will hear and feel clicks and taps followed by a pause. This is called mapping and it is helpful to use earplugs at this time. Your doctor will review the information collected to form a treatment plan for you that can be adjusted and modified, depending on your symptoms and side effects.
Subsequent treatments last around 40 minutes and you are awake and alert during them. Some people will experience mild scalp discomfort following treatments, but you can return to normal activities after and between treatments. Symptom relief may take a few weeks to occur, but if this treatment is effective for you, depression symptoms will improve or completely go away.
Is There Hope for Treatment-Resistant Depression?
For treatment-resistant depression, there is always hope. As difficult as it may seem to deal with the symptoms of treatment-resistant depression, there are many different ways to approach it and, with patience and support, you will achieve relief. Trust the process of trying different treatments and combining two or more as you create a lifestyle that is conducive to managing your depression in the best way for you.
Sage Neuroscience Center is New Mexico’s premier integrative behavioral health and physical care services facility that offers ketamine and TMS (Transcranial Magnetic Stimulation) for treatment-resistant depression. Contact us today to discuss personalized treatment options. Our caring, expert providers are here for you and understand what you are going through.
Don’t spend another day feeling helpless. Help is available and we are here to lead you to better days ahead.
Founder and Clinical Director
Dr. Reuben Sutter is the founder and Medical Director for Sage Neuroscience Center. He is board-certified in general adult psychiatry and addiction medicine. He is also the past president of the psychiatric Medical Association of New Mexico. His practice focus includes severe mental illness, substance use disorders, and treatment-resistant depression. He supervises the Transcranial Magnetic Stimulation service and assists in the ketamine clinic. These both focus on treatment-resistant depression.