Care for Treatment-Resistant Depression

Depression is often called treatment-resistant when it has not improved enough after trying more than one treatment. Sometimes the reason is a missed diagnosis, such as bipolar disorder. It can also be an untreated medical or sleep condition, or a medication that was not given enough time or the right dose. Many people with difficult-to-treat depression do find relief.

How our physicians help

Our physicians start with a detailed review of your history, past medications, therapy and health. From there, care can include adjusted medication strategies, psychotherapy, and coordination with specialists, when appropriate, for newer treatments such as transcranial magnetic stimulation (TMS), which uses magnetic pulses to stimulate parts of the brain involved in mood. The same physician follows your progress closely.

Signs it may be time for a fresh look

You do not need a formal label to ask for a second look at your care. Common reasons include:

• You have tried two or more treatments and still do not feel like yourself.
• You feel somewhat better, but poor sleep, low energy or a flat mood never lifted.
• A medication helped for a while, then seemed to stop working.
• Side effects kept you from staying on a medication long enough to know if it helped.
• Each prescriber changed one thing, and no one has looked at the whole picture.

What a second look at your treatment covers

Before adding anything new, your physician works out what has really been tested. Doctors call one common finding pseudo-resistance, which means depression looks resistant because an earlier treatment never had a fair chance. That can open up options you thought were used up.

We also ask what may be holding depression in place, such as chronic pain, ongoing stress or trauma, alcohol or cannabis use, ADHD, or other medications that lower mood. For each past treatment, we ask:

• How long did you take it, and did the dose reach a level expected to help?
• Was it hard to take every day, and if so, why?
• What changed, even a little, and what side effects appeared?
• Which kind of therapy did you have, and did it have a clear structure and goal?

Next steps with medication and therapy

What comes next depends on that review. Each step takes weeks to judge, and each added medication can add side effects. Changing one thing at a time makes it easier to see what helped. Options include:

• Switching to a different medication, often from another class, so that it works in a different way.
• Adding a second medication to boost the first, which doctors call augmentation. This may be another antidepressant, a mood stabilizer, or a type of antipsychotic medication used here to help mood.
• Starting a structured therapy you have not had, such as cognitive behavioral therapy or mindfulness-based cognitive therapy, which teaches you to step back from painful thoughts.

Treatments we coordinate with outside teams

Our practice is outpatient, and we do not provide these treatments. When one may fit, we refer you to a team that does and keep following your care. None works for everyone.

• TMS usually means frequent visits over several weeks. Scalp discomfort and headache are common.
• Electroconvulsive therapy (ECT) uses a brief electrical current to bring on a short, controlled seizure while you are under anesthesia. It is one of the most effective treatments for severe depression. Memory problems around the time of treatment are the main trade-off, and some gaps in memory can last.
• Ketamine and esketamine are given under medical supervision because they can briefly affect perception, alertness and blood pressure, and both carry a risk of misuse. Esketamine, a nasal spray, is FDA-approved for depression that has not responded to other treatment. Ketamine is used off label for depression, which means it is not FDA-approved for that use. They may act faster than standard antidepressants, but the benefit can fade, and long-term effects are still being studied.
• Hospital and day programs add structure and support when depression is severe or safety is a concern.

Helping someone with long-lasting depression

Long illness wears on partners and families too. Try not to offer new fixes, since 'have you tried' can land as blame. Ask what would help today.

It can also wear down hope. The belief that nothing will ever help comes from the depression itself, and it can shift even after years. If hopelessness turns into thoughts of suicide, call or text 988 (the Suicide & Crisis Lifeline) or call 911. We are not an emergency service.

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