Treatment-Resistant Depression

How well is your depression treatment working? Does it help, but not enough – and you still don’t feel as well as you used to? Or is your depression treatment simply not working at all?

If so, you could have treatment-resistant depression, also called refractory depression. Unfortunately, depression treatments don’t always work. As many as two-thirds of people with depression aren’t helped by the first antidepressant they try. Up to a third don’t respond to several attempts at treatment.

Treatment-resistant depression can leave you hopeless. Months or even years can go by without any relief. And after the effort it took to get help, it can be demoralizing when you’re just not getting better.

But if your depression treatment isn’t working, don’t give up. Many people can get their treatment-resistant depression under control. You and your doctor just need to find the right approach. This might include different drugs, therapy, and other treatments. If you’re still struggling with depression despite treatment, here’s what you need to know.

Understanding Treatment-Resistant Depression

What is treatment-resistant depression? Surprisingly, that can be hard to answer. Experts still disagree on what exactly the term means.

Many say that it’s a case of depression that doesn’t respond to two different antidepressants from different classes. Other experts say that a person needs to try at least four different treatments before depression can be truly considered treatment-resistant.

Of course for you, the exact definition doesn’t matter. You just need to ask yourself some basic questions.

* Has your treatment failed to make you feel better?

* Has your treatment helped some, but you still don’t feel like your old self?

* Have the side effects of your medication been hard to handle?

If the answer is yes to any of these, you need to see your doctor. Whether or not you actually have treatment-resistant depression, you need expert help.

Treatment-Resistant Depression: Getting Help

Although a primary care doctor can treat depression (research suggests that 60-65% antidepressants are prescribed by primary care physicians), it may be best to see a specialist, like a psychiatrist, if you think you may have treatment-resistant depression. It’s a good idea to also work with a therapist, like a psychologist or social worker, because the best treatment is often a combination of medicine and therapy.

Treatment-resistant depression can be hard to diagnose. Sometimes, other conditions or problems can cause similar symptoms. So when you meet with your doctor, he or she will want to:

* Confirm the diagnosis. Some people who apparently have treatment-resistant depression were misdiagnosed. They never had depression in the first place. Instead, they have conditions like bipolar disorder and have been getting the wrong treatment. Other people have dysthymia – a low-level, chronic depression – that is distinct from treatment-resistant depression.

* Make sure you’ve been using your medicine correctly. Up to half of all people who get prescribed drugs for depression don’t take them as recommended. They miss doses or stop taking them because of side effects. Some give up too soon – it can take up to 12 weeks for a medicine to take effect.

* Check for other causes. Other issues – ranging from thyroid problems to substance abuse – can worsen or cause depression. So can many medicines used to treat common medical problems. Sometimes, switching medicines or treating an underlying condition can resolve a hard-to-treat depression.

You may wonder why some people do so well with the first medication they try, while you continue to suffer. Experts don’t really know. But evidence suggests that people who have especially severe depression may also be harder to treat. A long duration of symptoms may also increase the risk – which is one reason it’s so crucial to get control of depression symptoms quickly. The longer depression goes on, the harder it may be to control.

Medications for Treatment-Resistant Depression

If your current medicine isn’t helping – or isn’t helping enough – other drugs might. There are two basic approaches.

* Switching medicines. If one medicine doesn’t work, your doctor will probably recommend trying another instead.

There are a number of different classes of antidepressants, including SSRIs (like Prozac or Celexa) and SNRIs (like Effexor and Cymbalta.) Older classes of antidepressants include tricyclics (like Elavil or Pamelor); tetracyclics (like Remeron); dopaminergics (like Wellbutrin) and MAO inhibitors (like Parnate or Nardil). These different types of antidepressants have different effects on the brain chemistry. Sometimes, switching from one class of antidepressant to another can make a difference.

Another option is to switch from one drug to another in the same class. A person who wasn’t helped by one SSRI could still benefit from a different one.

Only one medication, Symbyax, is approved by the FDA specifically for treatment-resistant depression. It’s a combination of the antidepressant fluoxetine (Prozac) and olanzapine (Zyprexa), a drug approved for bipolar disorder and schizophrenia.

* Adding a medicine. In other cases, your doctor might try adding a new medicine to the antidepressant you’re already using. This can be especially helpful if your current drug is helping but not completely relieving your symptoms.

What medicines might he or she try? One option is to add a second antidepressant from a different class. This is called combination therapy.

Another approach is called augmentation therapy – adding medicines not specifically approved to treat depression, like lithium, anti-anxiety drugs, anticonvulsants, antipsychotics, and others. One drawback to this approach is that the more medicines you take, the greater potential for side effects.

People have different reactions to the drugs used for treatment-resistant depression. The medicine that works best for one person might have no benefit for you. And unfortunately, it’s hard for your doctor to know beforehand what drug or combination of drugs will work best. Arriving at the right treatment can take patience.

Other Treatments for Treatment-Resistant Depression

Drugs aren’t the only approach used in treatment-resistant depression. Some other methods included in the treatment of treatment-resistant depression are:

* Talk therapy. Approaches like cognitive behavioral therapy – which focuses on concrete goals and how your own thoughts and behaviors contribute to your depression -- can really help people with depression. There’s some evidence it works well with treatment-resistant depression specifically.

One study looked at people who didn’t respond to an antidepressant. The researchers found that cognitive behavioral therapy led to a 50% improvement in symptoms – just as effective as trying another regimen of medicines. Although the evidence is limited, other approaches – like interpersonal or psychodynamic therapy – might also help.

If you’ve tried therapy in the past and it hasn’t helped, you could try again. Think about seeing a new therapist. Or look into a different therapeutic approach. For instance, if one-on-one therapy didn’t do much for you, you could give group therapy a try.

* ECT (electroconvulsive therapy.) ECT is typically used in people with serious or life-threatening depression that can’t be resolved by other treatments. It uses electric impulses to trigger controlled seizures in the brain. This treatment can rapidly relieve depression, although it’s not clear how long the effects last.

* VNS (vagus nerve stimulation.) This approach is also used in people with serious depression that just hasn’t responded to other treatments. Like ECT, it uses electrical stimulation to relieve the symptoms of depression. The difference is that the device is surgically implanted in your body. The evidence that VNS helps with treatment-resistant depression is unclear.

* TMS (transcranial magnetic stimulation.) This is a new non-drug approach that's been approved for treatment-resistant depression. Like VNS and ECT, it uses electrical stimulation to treat depression. Although TMS seems to be less effective than ECT, it's also safer and poses very few side effects. It may be best for people who have moderate depression. Treatment is done on an outpatient basis four to five days a week for four weeks.

* Other experimental techniques. Experts are researching new techniques to tackle treatment-resistant depression, like deep brain stimulation and MST (magnetic seizure therapy.) Although some studies have been promising, more research needs to be done. But if you’re interested in trying them, talk to your doctor about joining a clinical trial.

Sometimes, a doctor might recommend hospitalization for treatment-resistant depression. It could be the best option if your depression is severe and you’re at risk of hurting yourself. A stay in the hospital also offers a way for you to recover from your depression in a safe and stable environment. You’ll get a break from some of the daily stresses that might contribute to your condition. Your doctors will also get a chance to collaborate and come up with a good treatment plan.

Living With Treatment-Resistant Depression

Life with depression is hard, but treatment-resistant depression can be especially brutal. When one treatment after another doesn’t help, you can lose hope that you’ll ever feel better. All your efforts -- the doctor’s visits, the medication trials, the therapy sessions -- might seem like a waste.

But they haven’t been a waste. Arriving at the right treatment for depression can take time. It can take some trial and error. Look at it this way: if you try a particular treatment and it doesn’t help, you’re that much closer to finding the one that will make you feel better.

Whatever you do, don’t settle. Don’t give up and accept the symptoms of depression. Remember, the longer a depression goes on, the harder it may be to treat.

So instead, go back to your doctor and see if there’s something else you can try. There are so many good treatments for depression out there. You just need to find the right one for you.