By Gonzalo Laje, MD, as told to Kara Mayer Robinson
I am a psychiatrist, certified in child, adolescent and adult psychiatry. After my own personal experience with depression in my 20s, I have been on a lifelong quest to understand and help others.
I spent nearly a decade at the National Institutes of Health looking for ways to predict which depression treatments might be most effective for different people. Today, I lead Washington Behavioral Medicine Associates, a group practice in Chevy Chase, MD, where we help patients of all ages with treatment-resistant depression (TRD).
Here’s what you need to know about TRD and advances in treatment.
How do you know it’s TRD?
Most experts agree that the definition of treatment-resistant depression is the failure of two or more antidepressants, prescribed and taken at the maximum dose, for at least six weeks each.
What can you do if you have TRD?
There are many options for successful treatment of TRD. However, this does not mean that it will be easy to find a successful treatment.
My approach to TRD consists of providing support from multiple perspectives. I focus not just on medications for depression, but on an overall strategy that includes:
- Dietary changes
- Excercise
- Medical evaluation with extensive blood tests
- Medication
- Neuromodulation
- Psychotherapy
- Restorative sleep
- Supplements and vitamins, especially if we notice a deficiency
First I discover the details of previous treatments. It is important that your doctor understands how your symptoms have developed and how you have responded to previous treatments. Your doctor may ask you what medications you have tried, what the dosages are, how long you have taken them, and if you have had any side effects.
Then I look at the broader medical picture. Could other factors play a role? Do you have good sleep habits, diet and exercise?
I can recommend supplements, vitamins and medications to improve daily life. For example, vitamin D or omega-3 fatty acids can help improve mood. I also discuss the constant negative self-talk that accompanies depression.
Finally, I look for a combination of medications and neuromodulation to help your brain function in a more harmonious way.
What treatments are best for TRD?
Over the past 15 years, we have had a welcome introduction of various evidence-based strategies to treat TRD. This involves medications and techniques that involve brain stimulation or inhibition, which is called neuromodulation.
Medication. For TRD, we go beyond classic depression medications such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs).
We can use medications such as tricyclic antidepressants, lithium, thyroid hormone and monoamine oxidase inhibitors (MAOIs). We can combine these with other medications, such as atypical antipsychotics, buspirone or other mood stabilizers. The combination of possibilities is enormous.
Ketamine is an old anesthetic that has been shown to help relieve TRD within hours. This is a big difference from typical depression medications, which can take weeks to take effect. There is some controversy surrounding ketamine, but it offers hope for severe cases with limited options.
Neuromodulation. This is a treatment strategy that uses physical methods, such as electrical currents, to stimulate your brain.
One type is electroconvulsive therapy (ECT). It is poorly depicted in movies and has fueled misinformation and mistrust, but it is a very safe and effective method of treating depression. ECT sends a small dose of electricity through your brain to change your brain chemistry and reverse your symptoms.
Another type is repetitive transcranial magnetic stimulation (rTMS). This is an FDA-approved treatment that delivers a magnetic pulse through a coil placed in your scalp. The pulse can stimulate or inhibit nerve cells in the part of your brain related to mood control.
rTMS has minimal side effects and the results are positive. It is my preferred method and I often combine it with other treatment strategies.
What other treatments can doctors try for TRD?
Light therapy is an established treatment option for people whose depression may be seasonal. If your mood worsens in the autumn months, it may have a seasonal component.
Light therapy can relieve symptoms, improve sleep and increase energy. It depends on the device, but your doctor may recommend using light panels or goggles for about 20-30 minutes every morning, starting in the fall.
Psilocybin, or ‘mushrooms’, has been studied for years as a possible treatment for depression. It’s not clear whether it is better than traditional antidepressants, but it may have fewer side effects. It may be an option if you’ve tried other things and they haven’t worked. Talk to your doctor to see if this is a good option for you.
Nitrous oxide (N2O), better known as ‘laughing gas’, can help with depressive symptoms. It works quickly and can be similar to ketamine. But there is no clear strategy yet for using N20 for depression. This may change in the near future as more research is now done.
Does psychotherapy help TRD?
Psychotherapy is an important part of your treatment strategy.
In most cases, I prefer talk therapy strategies that focus on the here and now. Therapies that help you solve problems, understand why you feel stuck, promote a healthy mind-body connection, and help you recognize and cope with emotions are often the most effective.
Depending on your situation, one form of therapy may be better than another. In many ways, I think of different types of therapy through the same lens as different medications: some work better for one type of problem and some work better for others.
What are common challenges in treating TRD?
The first challenge is making the correct diagnosis. To find the best treatment, it’s important to understand other conditions you may have, such as anxiety, obsessive-compulsive disorder, personality disorder, or other medical problems.
Since we don’t yet have good predictors to know whether to choose one strategy over another, it’s a process of trial and error. This can be challenging and can cause anxiety and frustration.
What can you do to increase your chances of finding a treatment that works?
Work with your doctor and a therapist to try different strategies. It may be helpful to consult an experienced psychiatrist or psychopharmacologist.
There are many treatment options. I’ve heard many patients say, “I’ve tried them all,” “Nothing is going to help me,” or “You don’t know what it’s like.” But depression is a disease like any other. If your treatment doesn’t seem to be working, it may be time to discuss other strategies with your healthcare provider.