Treatment-Resistant Depression
Condition
What the term means
Treatment-resistant depression describes major depressive disorder that has not responded adequately to at least two antidepressant medications, each taken at an adequate dose for an adequate length of time. The definition varies somewhat between clinicians and between insurance policies, but that is the general standard.
The term describes a treatment history rather than a person or a prognosis. It is a common situation, and it does not mean that depression cannot be treated. In practice, it means that the ordinary first steps have been taken and that the next steps require a more careful look at what has happened so far.
Review
What we look at first
Before adding another treatment, we review what has already been tried. Prior medication trials are frequently recorded incompletely, and a medication remembered as ineffective was sometimes taken at a low dose, for a short period, or during a stretch when it was taken irregularly. For each medication, we ask about the dose, the duration, the response, and the reason it was stopped. Prior records are helpful, and we will request them with your written authorization.
The same review applies to therapy, to any prior interventional treatment, and to periods when treatment was interrupted for reasons unrelated to how well it was working.
We also reconsider the diagnosis. Depression that has not responded to treatment is sometimes depression that has not been fully characterized. We evaluate for bipolar disorder, attention-deficit/hyperactivity disorder, post-traumatic stress disorder, obsessive-compulsive disorder, and substance use disorders, any of which may be present alongside the depression or in place of it. Where a different diagnosis emerges, the treatment plan changes accordingly.
Medical contributors are reviewed as well. Thyroid disease, sleep apnea, anemia, vitamin deficiency, chronic pain, and the side effects of medications prescribed for other conditions can all sustain a depression that would otherwise respond to treatment. Laboratory testing may be ordered as part of this review.
Finally, we look at what has been going on around the treatment. Ongoing insomnia, alcohol use, an untreated anxiety disorder, or a difficult and unresolved situation can each limit what any antidepressant is able to do.
Treatment
How we treat it
Once the review is complete, we will discuss the available options and the order in which they might be tried. Depending on your history, that may include optimizing the dose of a medication you are already taking, changing to a medication from a different class, adding an augmenting medication such as lithium, an atypical antipsychotic, or thyroid hormone, or adding therapy within your visits.
Interventional treatments are also available here. Transcranial magnetic stimulation (TMS) is FDA-cleared for major depressive disorder in patients who have not responded adequately to antidepressant medication, and it is provided in our office over a course of daily sessions. Esketamine (Spravato) is FDA-approved for treatment-resistant depression, taken together with an oral antidepressant, and we are a certified treatment center. Both are described in detail on the TMS page and the Spravato page.
Because these treatments are provided within one practice, moving from one to another does not require a referral elsewhere or a change of physician.
We will also discuss what we would recommend next if a given step does not produce the response we are hoping for, so that the plan does not stall while another appointment is arranged.
The term describes a treatment history rather than a person or a prognosis.
Schedule
Getting started
Treatment-resistant depression is treatable, and there are more options available than there were even a few years ago. Schedule an appointment today and bring what you have — a current medication list or the bottles themselves, and any prior records, including previous evaluations and testing. You may call 972-332-5922 or book online.