How Treatment-Resistant Depression is Treated

Treatment-resistant depression (TRD) is defined as depression that does not adequately respond after trying at least two medications. TRD is not an official DSM diagnosis, but it is used to identify those who may be candidates for different types of treatments.

The major areas of treatment for TRD are medications (including everything from SSRIs to antipsychotics), psychotherapy, ketamine and more invasive procedures, such as electroconvulsive therapy. People with treatment-resistant depression are more likely to be hospitalized and/or attempt suicide, so it is key to find adequate ways of treatment that work—and quickly.

Read on to learn more about some treatments that may work for depression that has previously been treatment-resistant. 

Psychotherapy

In studies of psychotherapy in addition to usual care, the following psychotherapies were successful in achieving a reduction in depression symptoms/scores, both self reported and via depression scales such as PHQ or HAMS-(D).

Additionally, as many people with treatment-resistant depression may tend to isolate, having steady contact with a therapist can be helpful. Moreover, many studies have confirmed that psychotherapy and medication typically work synergistically, magnifying the effects of each other.

Below are some of the psychotherapies that have been proven helpful for TRD:

Cognitive Therapies

Most of the therapies that have been studied to be helpful in TRD are cognitive-based, meaning that they operate on the assumption that thoughts, feelings, and behaviors are all connected, and that people can overcome difficulties by changing unhelpful thinking and distressing emotional responses.

• Cognitive Behavioral Therapy: CBT was found to have the longest effectiveness, with one study showing positive results at both 12- and 46-month intervals.
• Dialectical Behavioral Therapy: DBT is a type of CBT that teaches people to live in the moment, live mindfully, and find healthy ways to deal with stress and their emotions by learning relevant skills.
• Cognitive Behavioral Analysis: This is a type of therapy created specifically to deal with depressive disorders and is a combination of interpersonal, cognitive, and behavioral therapies. Its main goal is to help people understand their interpersonal worlds and how they affect their behaviors so that they can meet interpersonal goals.
• Interpersonal Therapy: TRD particularly responds to interpersonal therapy because medication cannot, on its own, fix interpersonal difficulties that someone may be having that are reading to their depression.
• Intensive Short-Term Dynamic Psychotherapy: This is a modality, brief in duration, that helps people identify and address the emotional factors behind their depression by building emotional capacities.

Medication

Most people who are diagnosed with major depressive disorder (which is what you are generally diagnosed with and treated for before it progresses to TRD) are started on SSRIs or SNRIs. However, anywhere up to a third of people do not respond to SSRIs/SNRIs. Because this is so common, psychiatrists often use the following treatment algorithm to determine next steps:

• Optimizing: Starting on an antidepressant (SSRI/SNRI/TCA/MAOI) and ensuring that it has been given an adequate trial, by both dosage and duration
• Switching: Changing from one class of antidepressant to another (ie from an SSRI to an MAOI)
• Combination: Adding antidepressants from different classes, (ie SSRI + atypical antidepressant, such as bupropion.)
• Augmentation: Adding a second medication that is not an antidepressant but may enhance the antidepressant effect of the initial drug, such as lithium, psychostimulants, atypical antipsychotics (such as quetiapine, aripirparzole, olanzapine and risperidone), thyroid hormones

The biggest drawback to any of these more traditional medications is how long it takes them to work. Many of them may take up to six weeks to work fully—which can feel like an eternity when you’re struggling. Additionally, they may come with sexual side effects or side effects like weight gain.

Much research is being done right now in depression treatment and several of the below treatments have either been approved or appear to be on the precipice of it:

• Ketamine/Esketamine: Studies first confirmed in the early 2000s that ketamine has antidepressant properties, but its popularity has exploded in the past few years, including esketamine, a nasal spray delivery system, being approved by the FDA in 2019. Also, regulations that were relaxed on account of the pandemic allowed at-home ketamine services to flourish (though they are often very expensive).
• Auvelity: In August 2022, the FDA approved a new antidepressant called Auvelity (dextromethorphan - bupropion), which is based on research on how ketamine works in the brain. Auvelity also works faster than traditional antidepressants—often working within a week.
• Psilocybin: If you follow any kind of mental health/depression news, you probably know that psilocybin and psychedelics in general are having a moment right now. In fact, recent research shows that even one session of psilocybin can bring relief to people dealing with depression. It is expected that psilocybin will receive FDA approval for treating depression in early 2023.
• Anti-Inflammatories: Some theories of depression—particularly TRD—associate it with higher levels of inflammation, and research is also currently being done on treating those with high levels of inflammation with anti-inflammatories—which don’t seem to work as well on people with depression who don’t have high levels of inflammation.

Surgery and Neuro-Therapeutic Procedures

While many typically think of depression/mental health treatment exclusively in terms of psychotherapy and medication, there are also a number of other medical interventions. Often they are reserved (and only covered by insurance) for after other treatments have failed:

• Transcranial Magnetic Stimulation: Transcranial magnetic stimulation (TMS) is a treatment that uses a device to administer magnetic stimulation to parts of the brain and has been found to help with symptoms of depression. Typical protocols were five times a week for six weeks, but a newly approved protocol, called the Stanford Accelerated Intelligent Neuromodulation Therapy was recently approved, which cuts the course of treatment down to just a week, and with some patients responding more robustly.
• Deep Brain Stimulation (DBS): This is another treatment that electrically influences the brain, but it is more invasive than TMS. This is a surgical procedure that implants a small pacemaker-like device in one’s chest with electrodes placed to target specific areas in the brain.
• Vagus nerve simulation is very similar to DBS, except that the electrodes are placed on the vagus nerve (which is central in the regulation of internal organ function) rather than the brain. Stimulation this nerve has been found to influence mood.
• Electroconvulsive therapy (ECT): Electroconvulsive therapy has gotten a bad reputation over the years, but in depression that’s really not responding to anything else, it can be incredibly helpful. It is still generally considered the most effective modality for treatment resistant depression.

Complementary Alternative Medicine (CAM) & Over-the-Counter (OTC) 

While no real “over the counter” remedies exist for depression the way they do for, say, allergies, there are some supplements and other over-the-counter products that may help with depression as well as other types of complementary and alternative medicine (CAM) that might have potential benefit.

• St. John’s Wort: This is an herb that has some evidence of reducing severity of depression and improving response rates. However—it may limit the effectiveness of certain antidepressants or even lead to the life-threatening serotonin syndrome if taken with certain other medications, so do not take it without consulting with a doctor.
• Omega 3: Popular opinion would say that Omega 3 fatty acids reduce symptoms of depression, and some studies do support this, but a recent meta-analysis of 31 trials found no strong evidence of this.
• 5-HTP: This is an amino acid that, dietarily, can be found in l-tryptophan-rich foods like turkey or red meat. In the body, it can be converted to serotonin, which helps regulate mood. Research shows that supplementing with 5-HTP can be helpful both on its own or in conjunction with an antidepressant, though too much 5-HTP may lead to serotonin syndrome.
• SAM-e: S-adenosyl-L-methionine, more commonly known as SAM-e, is a compound that is typically found in the body that helps regulate hormones is involved in a variety of other functions. Supplementing with it, either alone or in conjunction with an antidepressant, may help neurotransmitters better do their jobs.
• Rhodiola Rosea: This is considered an adaptogen, meaning it helps your body better adapt to dealing with stress and may be supplementally helpful for some people with depression.
• Acupuncture: Research is somewhat inconclusive, but some data does suggest that acupuncture may help with depression by blocking stress hormones and the stress response that often show up in depression. While data may be inconclusive, there may be little harm in attempting acupuncture.
  

Diet and Exercise

If you are dealing with treatment-resistant depression, your mind likely isn’t on eating healthfully or exercising, but what we put into our bodies and how we move them can have a real effect on our mental health.

Diet

When you’re dealing with treatment-resistant depression, it’s likely your eating habits are affected. You’re either eating too much, not enough, or eating lots of comfort food, which may raise inflammation levels, which are thought to contribute to treatment-resistant depression.

But you don’t have to overhaul your whole diet all at once. Small changes, such as reducing processed food in your diet and remembering to eat breakfast may go a long way.

Exercise

Yoga: If you had a dollar for every time someone has asked you if you’ve tried yoga, you’d probably be able to pay for your treatment on just that. But it’s for good reason—while it won’t cure depression, it may reduce the symptoms and severity of it.

Walking: If, when you’re not depressed, you’re typically a person who goes hard on their exercise, you may scoff at the idea of walking for depression. However, walking and other moderate-intensity exercise, when done regularly, may even lead to improvement of depression symptoms.

Things You Can Try on Your Own

While treatment-resistant depression is incredibly serious and does require working with a professional, there are some other types of treatments you can do at home/on your own.

• Light therapy: Especially in the winter months, or if you live in a dark/cold climate, your circadian rhythms may be affected by the lack of sunlight, but the good news is that light boxes may actually help depression. Many people begin seeing benefits within the first week of using them daily.
• Bibliotherapy: One very low-cost way you can manage your treatment-resistant depression is through bibliotherapy—a fancy word for reading. Reading, particularly fiction, can help people with depression, as it helps them by getting lost in others’ worlds and forgetting about their problems as well as understanding themselves better. There are also actually several books that have been specifically studied to help in depression—Feeling Good by David Burns or Controlling Your Depression by Peter Lewinsohn. Essentially, both of these books are CBT manuals, and you are teaching yourself CBT principles.
  
• Expressive writing: Psychotherapy is immensely helpful at helping people process their emotions, but it’s typically only once per week. What do you with all of those feelings in between? Expressive writing is a form of journaling, but rather than just write about the events that happened, it involves processing the emotions you feel about this event. It can help you feel like you have a sense of control over the events that are happening your life and may even be cathartic, therefore reducing symptoms of depression.
  
  

How to Make Your Treatment Most Effective

Medication Adherence

If you are not taking your medication daily or regularly as prescribed, it can be hard for it to be effective. Depression, however, can also make remembering to take it in the first place difficult. Some strategies that may help include setting a timer on your phone, using a pill case, or keeping your medications out in a place where you can’t miss them.

Avoid Alcohol and Other Drugs

Alcohol is a depressant, so it may make your depression worse and negate any help that your antidepressants are giving you, for a double whammy. Other drugs, particularly addictive ones, may cause further mental health issues.

Minimize Stress

We know, we know, easier said than done! However, stress only aggravates feelings and symptoms of depression. While there are plenty of stressful situations that are beyond our control, what we can control is how we deal with those situations as well as not inflicting any unnecessary stress on ourselves. Self-compassion can go a long way in helping deal with stress.

Consider Cost

Unfortunately, in the United States, mental health treatment can be incredibly costly and out of the reach of many. However, going into debt for your depression treatment will only create more stress, so look into things like reduced fee treatments.