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Treatment Resistant Depression

New therapies including TMS and esketamine are showing breakthrough success.

Treatment-resistant depression (TRD) perfectly embodies the phrase “adding insult to injury.” Depression is difficult enough to live with, but when it’s resistant to treatment despite your best efforts, that’s a huge challenge for the person who is living with it.

But it’s a challenge you can win. In this article we discuss symptoms, possible causes, conditions that can exacerbate the depression, plus medications and therapies that may bring lasting relief. We’ll also look at two particular treatments SunCloud Health is now using that are showing real results for people with TRD.

If you have TRD, or suspect you do, we empathize. And we applaud you for making the effort to learn more about it, so you can get better.

What is TRD?

Treatment-resistant depression (TRD) is most often defined as depression that does not respond to at least two different treatments in doses and timeframes that would normally bring significant relief. It is estimated that about a third of people with depression are dealing with TRD. There’s a misperception that TRD always involves severe symptoms, but that isn’t true. Symptoms can be mild but persistent—and yes treatment resistant.

How to know you have TRD

TRD may present itself in a number of ways, including:

Lack of response to at least two medications.
Small, inadequate response to medications.
Short-duration improvements followed by a return to full depression symptoms.

If left untreated, TRD symptoms can go on for months and even years with no relief in mood.

Confirming your TRD diagnosis

If you think you may have TRD, it is vital to see a primary care physician or, better still, a psychiatrist with expertise in depression. This person can confirm your diagnosis, and start you on a treatment plan. Certain conditions and circumstances can mimic TRD symptoms, so you want to be sure you get an accurate diagnosis. Factors you’ll want to cover with your provider include:

Life situation: Are there things going on in your life that are keeping you down? Chronic stress at work? The death of a spouse, loved one, or long-time friend? Ongoing money or health worries?

Other drugs or supplements you’re taking: Certain medications or supplements may be interfering with your depression medications and therapy.

Medication compliance: It’s important to be honest about the medications you’ve been prescribed. If you frequently skip doses, that may be why you’re not feeling relief from your depression symptoms.

Your physical health: Some conditions can cause or exacerbate depression, including thyroid disorders, chronic pain, or serious illnesses like cancer or heart disease.

Your mental health: It’s possible you may have another undetected mental illness such as bipolar disorder or an eating disorder. Both will require a different treatment strategy than the one you’re following for your depression.

Again, any one of these factors above may help explain why you’re not responding to treatment. Be sure to talk to a trained professional about them. You deserve to feel better.

Are there known risk factors and causes of TRD?

Some groups seem to be more likely than others to have TRD. These include women, seniors, and people with a severe form of depression.

Risk is also higher for people with certain illnesses such as thyroid disease and conditions that involve chronic pain. People with substance use issues, as well as sleep and eating disorders, may also be at higher risk of TRD.

As for underlying causes, again, the research isn’t crystal clear yet. Possible culprits include:

Not finding the right medication. Some meds just don’t work for some people, and it may take you and your doctor a while—as in more than two tries—to find one that does. Hang in there, keep on it, and stay hopeful.
Not giving your medicine a chance to work. Depression medications can take six to eight weeks or more to reach full effect. It’s important to be patient when trying a new medication, or a different dose.
Skipping doses. We covered this one above, and it may be why you think you have TRD but actually don’t. Do your best to take your medication exactly as prescribed.
Drug interactions. As with any medication, the drug you take for depression may not “play well” with other drugs or supplements you take. Check with your doctor about this.
Your genetics: Researchers are now looking at the genetic basis of TRD, but there’s no test yet that shows which medications will work best.
Metabolic abnormalities: It’s possible that metabolic disorders and even nutritional deficiencies may contribute to TRD. For example, one study found that people with TRD were more likely to have a folate (vitamin B9) deficiency.

Find out if SunCloud can help your TRD

Send a direct message to our care team. Or call us anytime, day or night:
1-866-729-1012

How you treat TRD

As with most other mental illnesses, the best way to treat TRD is usually with a combination of medication plus talk therapy.

Medication strategies to discuss with your doctor:

Increase your dose. People respond to medications differently, so you may need a higher dose than is usually prescribed. Ask your doctor if this strategy might work for you. (Note: NEVER change your dose without checking with your provider first, as that can be dangerous to your health.)
Switch antidepressants. Sometimes it takes a while to find the right medication. Unfortunately, it can be trial and error at first. With your doctor’s guidance, you may need to try several before you find one that works for you.
Add another type of antidepressant. Many people do best when they take different classes of antidepressants at the same time. The cumulative effect can offer better relief of your symptoms.
Add a medication used for another condition. Sometimes it works best to take a medication that is normally prescribed for another mental or physical health problem, along with your antidepressant. This is called augmentation. Medications may include thyroid hormones, antipsychotics, anti-anxiety medications, and other drugs. Check with your doctor about this.
Consider pharmacogenetic testing. These tests check for specific genes that indicate how well your body can process (metabolize) a medication.

Behavioral therapy to consider:

Again, behavioral or “talk” therapy can be very effective in tandem with medications in the treatment of TRD. With your therapist or psychologist, you can learn behaviors and strategies that can help you overcome your depression.

Your provider can help you:

Recognize and better deal with past emotional trauma.
Manage relationships in a healthier way.
Learn how to live less stressfully, and more calmly.
Address substance use issues.
Find better ways to face everyday challenges.

Four types of talk therapy are often used for TRD, including:

Cognitive behavioral therapy (CBT)
Cognitive behavioral analysis system of psychotherapy (CBASP)
Interpersonal therapy (IPT)
Radically open dialectical behavior therapy (RO-DBT)

CBASP is a newer therapy that was developed specifically to help people manage TRD. IPT helps you improve your interpersonal and social functioning to reduce depression. RO-DBT is another newer therapy that has shown results for TRD.

CBT is the probably the most popular therapy for TRD, and for depression generally. We use it a lot at SunCloud Health. With CBT, a therapist or psychologist helps you examine your thoughts and emotions and how they affect your actions. CBT can help you reframe negative thoughts, get better at problem-solving, help you increase social interaction, and boost your activity level. Many people with TRD experience distorted ways of thinking. CBT helps you “rewire” those thoughts, allowing you to change your outlook to feel more positive.

Two therapies showing great promise for TRD

We use both of these at SunCloud Health, and we’re getting excellent results. One is nasal spray called Spravato (esketamine). The other is a non-invasive procedure called transcranial magnetic stimulation (TMS). Both are helping people gain remission from TRD, and they’re FDA-approved for adults.

Spravato (esketamine):

Derived from ketamine, an analgesic that for decades has been used to fight pain, esketamine (brand name Spravato) is given via nasal spray over several weeks and has been shown in clinical trials to be safe and effective in patients with TRD. Esketamine is normally used in combination with oral antidepressants as well as talk therapy.

In a study published in JAMA Psychiatry, 70 percent of test subjects with TRD who took esketamine along with an oral antidepressant saw a significant improvement in their symptoms.

Transcranial magnetic stimulation (TMS):

This is a noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression. Its effectiveness for TRD has been well established in the scientific literature.

It involves delivering repetitive magnetic pulses, so it is sometimes called repetitive TMS, or rTMS. In depressed patients, the electrical activity in certain areas of the brain is shown to be reduced. TMS targets these areas, reawakening the cells and increasing brain activity. TMS treatments are normally given over a period of six weeks.

To learn more about these two promising treatments and SunCloud Health’s depression program in general, call us now at (866) 729-1012.

Other ways to feel better when you have TRD

With TRD, it can be hard to stay engaged in life. These strategies can help:

Simplify your life. As much as possible, keep things simple, stay organized, and structure your days with a short to-do list or by using a planner.
Write in a journal. Journaling is great for getting that clutter out of your head and into your journal where you can see it more clearly—or dispense with it altogether.
Stay connected. Make a point of getting together with family or friends regularly, even if you don’t really feel like it. Many times, it will go better than you expected, and you feel better for doing it.
Learn ways to relax and manage your stress.This might mean meditation, muscle relaxation exercises, yoga, tai chi, or just five quiet minutes of calm, concentrated, deep breathing exercises while seated in a chair.
Sleep well. Poor sleep can make depression worse—and of course depression negatively affects sleep. To break out of this bind, look into ways to improve your sleep habits or ask your doctor or mental health provider for advice.
Get regular exercise. Exercise has a direct effect on mood. Even physical activity such as housework, dancing, and gardening can reduce stress, improve sleep, and ease depression symptoms.

Final thought: Please remember, it may be called treatment-resistant depression, but it is treatable. Do your best to advocate for yourself when you’re using healthcare, check in with your doctor or therapist if you’re not seeing progress, and don’t ever give up. Relief is out there for you. It’s just a matter of finding it.

Schedule your TMS or esketamine consultation now