When a person suffering from depression does not have a response to standard treatments can be frustrating. This state of depression is known as treatment resistant depression (TRD).
TRD is defined as having no adequate response to at least two separate antidepressant treatments at an adequate dose and length of time. TRD is certainly not unusual, with the literature suggesting that approximately one-third of people with major depressive disorder are wound up classified as TRD.
This blog will examine how psychiatrists deal with treating TRD, the characteristics of TRD as a clinical condition versus other forms of depression, and some practical approaches that may be working for the purpose of real-world care.
Recognizing Treatment-Resistant Depression
Diagnosing treatment resistant depression (TRD) is not simply a matter of counting the number of failed medications. First of all, the psychiatrist wants to be accurate with their diagnosis because sometimes what appears to be TRD is misdiagnosed illness, such as bipolar disorder, or depression complicated by undiagnosed anxiety, past trauma, or other factors.
Second, the psychiatrist may want to ascertain medication adherence, or at least whether the patient had taken their medications as prescribed. Third, they want to determine the dosage (what was prescribed), and duration of treatment (length of time taking it).
In many cases, patients may also have external stressors related to life situations, have drug and alcohol use problems, or have other medical co-morbidities (e.g., weight, thyroid, chronic pain) that might blunt medication response.
Understanding the Individual Behind the Diagnosis
No two patients with TRD are the same. A psychiatrist takes time to explore the patient’s history, family background, childhood trauma, personality, coping skills, and current lifestyle. This personalized evaluation helps determine if certain therapies or medications might be better suited.
Psychiatrists also consider genetic testing in some cases. Pharmacogenomic testing may reveal how a patient metabolizes certain drugs, which could influence their side effects or lack of response.
Finding the Right Psychiatrist Near Me for Depression
The first step in managing treatment-resistant depression is finding a psychiatrist near me for depression, and a psychiatrist that listens and cares about you. Not all psychiatrists conceptualize depression in the same way. Some may only prescribe medication, while others provide a whole toolbox of support, therapy, and new options.
Look for:
- A psychiatrist who is board-certified and treats mood disorders
- a psychiatrist who sees you as a person and not just a diagnosis
- a provider who can help with medication management, lifestyle shifts, and talk therapy
- a clinic that takes your insurance.
This is an important choice! A strong therapeutic alliance is known to positively affect the healing process.
Step One Is Looking Again at the Diagnosis
The best psychiatrists ask the honest questions first. Obviously, it’s possible to have pure major depression, but in some cases this confusion requires us to rule out other possibilities like bipolar disorder, unresolved trauma, or some other medical nature.
Some possibilities they might ask about include:
- Were medications taken for long enough at the appropriate dose?
- Were you misdiagnosed?
- Is anxiety disorders, PTSD, or ADHD complicating the situation?
- Is depression somehow tied to a medical condition, like issues with your thyroid or lack of vitamins?
Harboring clarity about what’s really going on helps greatly to help avoid the chronic dissatisfaction of trial-and-error. The aim is to treat the root, not the symptom.
Medication Strategies for TRD
Medication changes are often the first step. Options include:
- Switching antidepressants: Moving from one class (like SSRIs) to another (such as SNRIs or atypical antidepressants).
- Augmentation: Adding a second medication, such as lithium, an antipsychotic, or a thyroid hormone to boost the effect.
- Combining antidepressants: Using two medications that act on different neurotransmitter systems.
These approaches are typically guided by the patient’s previous response, tolerability, and side effect profile.
Psychotherapy Still Matters
Therapy should not be ruled out, even when medications are unsuccessful. Cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) can be helpful for some persons with TRD. Psychotherapy can assist some patients in developing resilience or revising clearly distorted thinking, and “un-seeking” and returning to their goals in life.
At times, psychiatrists may refer patients for trauma-focused treatments, like EMDR (Eye Movement Desensitization and Reprocessing), when trauma is significant.
Exploring Advanced and Interventional Treatments
If medications and talk therapy do not work adequately, psychiatrists may recommend interventional options:
Electroconvulsive Therapy (ECT):
ECT is the most effective treatment for severe TRD and should be considered for patients who are experiencing psychotic depression, suicidality, or catatonia. ECT has a reasonable safety and efficacy profile but often falls into the not reasonable options category due to stigma.
Transcranial Magnetic Stimulation (TMS):
TMS is an FDA approved noninvasive treatment that uses magnetic pulses to stimulate mood-regulating brain regions, and is being used more and more because of limited side effects and a favorable safety profile.
Ketamine and Esketamine:
Currently, rapid-acting antidepressants like IV ketamine and nasal esketamine are revolutionizing the treatment of TRD. Unlike traditional medications that act on serotonin, the rapid-acting treatments act on glutamate to elicit a mood lift in a few hours instead of weeks. While this treatment is not for everyone, many patients are finding that it meets a previously unmet need after trying reasonable treatment options with traditional antidepressant medications.
The Role of Lifestyle and Functional Interventions
Psychiatrists are placing more emphasis on wellness as part of treatment for TRD. Even modest lifestyle interventions can encourage recovery. Psychiatrists may also address factors outside your ‘medical’ care in support of treatment. Examples include the following:
- Exercise: Frequent exercise releases endorphins, which can elevate your mood.
- Sleep hygiene: Sleep disruptions can have negative effects on depression and can even impact treatment response.
- Nutrition: Eating a Mediterranean-style diet composed of predominantly whole foods, containing omega-3s can promote brain health.
- Mindfulness practices: Mindful practices including yoga or meditation can reduce stress and may help to identify possible triggers for depression.
Social connection is equally important. Feelings of loneliness can lead to more depression. Encouraging social connection might include participation in support groups, volunteer opportunities, or community service, all of which can provide a sense of purpose.
Collaborative and Compassionate Care
TRD usually takes a team approach to treatment. Psychiatrists will often have primary care physicians, psychologists and even family involved in a collaborative approach to coordinated care. While all patients hope for an efficacious treatment, the psychiatrist recognizes how hope can be diminished when treatments do not work. Therefore, emotional support and transparency are vital in these situations.
Those suffering from treatment-resistant depression can recover, but it will take some time, a lot of effort, and a willingness to try other routes.
Final Thoughts
Treatment-resistant depression is challenging, but it is not hopeless. Advances in psychiatric care are opening new doors for people who once felt stuck. If you or someone you love is struggling, know that options exist—and with the right care, improvement is within reach.
If you or someone you love is dealing with TRD, know that there are options. Start by finding an affordable psychiatrist near me who will explore every angle of care—because the right support can change everything.
