Treatment Resistant Depression (TRD)—the words no mentally interesting person wants to hear. It is a heavy weight to carry. It’s bad enough to be depressed, but to have no or very little respite from it is awful.
I have had TRD most of my life. I have had brief periods where I was symptom-free, but now I find myself having undertaken most of the available options. I am currently taking eight psychotropic medications in an attempt to blot it out. My next step is ketamine infusions, a somewhat controversial method of treating TRD.
What is TRD? According to “Mental Health Clinician,” it is the lack of significant improvement after two adequate trials of two different anti-depressants from two different pharmacological classes. It can range from mild to severe.
What are some beginning steps you can take for TRD?
-Give current medications more time. Most anti-depressants take anywhere from 2-8 weeks to begin working.
-Increase your dose. Your doctor will likely start you on the smallest dose of a medication and then work up depending on your response.
-Switch anti-depressants. Often the first medication you try will not be the one to reduce your symptoms.
-Add another type of anti-depressant. There are Selective Serotonin Re-uptake Inhibitors (SSRIs) Ex: Prozac; Serotonin-Norephinephrine Re-Uptake Inhibitors (SNRIs) Ex: Cybalta; Atypical Anti-depressants Ex: Wellbutrin; Tri-cyclic Anti-depressants Ex: Elavil; and Monoamine Oxidase Inhibitors (MAOIs) Ex: Nardil.
-Add a medication generally used for another condition, including anti-psychotics, thyroid hormones or other drugs. This is also known as using medication for an “off label” use.
-Consider P450 testing which checks for specific genes that indicate how well your body can process certain types of medications.
You can also try various types of counseling in conjunction with medication such as:
-Cognitive Behavioral Therapy (CBT) helps patients understand the thoughts and feelings that influence behavior;
-Acceptance and Commitment Therapy (ACT) helps patients open up to unpleasant feelings and learn not to overreact to them. Leads to a better understanding of the truth;
-Interpersonal psychotherapy is a time-limited, focused, evidence-based approach to treat mood disorders. It improves the quality of the patient’s interpersonal relationships and social functioning to help decrease their distress;
-Psychodynamic therapy is designed to reveal the unconscious content of a patient’s psyche in order to relieve psychic tension; and
-Family or marital therapy
There are also a few procedures you can try including:
-Electroconvulsive Therapy (ECT). ECT involves a brief electrical stimulation of the brain while the patient is under anesthesia.
-repetitive Transcranial Magnetic Stimulation (rTMS) A electromagnetic coil is placed against your scalp near your forehead. The electromagnet painlessly delivers a magnetic pulse that stimulates nerve cells in the region of your brain that involves mood control and depression.
-Vagus Nerve Stimulation. An implantable vagus nerve stimulator is placed inside the skin on your chest, connecting the device to the left vagus nerve. When activated, the device sends electrical signals along the nerve to your brain stem which then sends signals to certain areas of the brain.
-Ketamine Infusions. It is not known exactly how it works, but one idea is that by elevating glutamate levels, ketamine helps nerve cells re-establish connections that were disabled by depression.
Aside from medical interventions, its important to:
-stick to your treatment regimen. Don’t skip pills and take everything as directed. Inform your doctor of any changes you would like to make.
-abstain from alcohol and/or recreational drugs. Although it’s tempting to drown or smoke your depression away, this can often exacerbate the problem.
-manage your stress. Whether through meditation, journaling, engaging in a hobby or just spending time with loved ones, figuring out ways to manage your stress is essential.
-get good sleep. Make a real effort to go to bed and get up at the same time each day.
-regular exercise. There are a number of studies linking exercise to a decrease in symptoms.
TRD is not an unsolvable problem, but it does take time and patience.
Do you have TRD? What have you done to try to resolve it?
American Psychiatric Association. “What is Electroconvulsive Therapy?”
The Comprehensive List of Anti-depressants. RxList
Healthline. Rachael Nall. September 16, 2016. “Repetitive Transcranial Magnetic Stimulation.
Mayo Clinic. Cognitive Behavioral Therapy (CBT).
Mayo Clinic. Monoamine Oxidase Inhibitors (MAOIs).
Mayo Clinic. Selective Norepinephrine Reuptake Inhibitors (SNRIs).
Mayo Clinic. Selective Serotonin Uptake Inhibitors (SSRIs).
Mayo Clinic. “Treatment Resistant Depression: Sometimes Depression Doesn’t Get Better, Even With Treatment. Explore what you can do about it.” Mayo Clinic Staff. July 12, 2017.
Mayo Clinic: Tricylic Anti-depressant.
Mayo Clinic. Vagus Nerve Stimulation.
Psychology Today. Acceptance and Commitment Therapy (ACT).
Tanner, Lindsey. October 31, 2018. “Trippy Depression Treatment? Hopes and Hype for Ketamine.”
Werrenger, Amy. 2014. Treatment Resistant Depression. Mental Health Clinician. September 2014, Vol. 4, No. 5, p. 211
Wikipedia. Psychodynamic Therapy.