Treatment-resistant depression (TRD), also known as refractory depression, is a form of major depressive disorder (MDD) that does not respond adequately to at least two different kinds of treatment, usually including antidepressants. I offer therapy for treatment-resistant depression, usually in conjunction with other providers such as psychiatrists. In some cases, I do consider TRD to be defined as symptoms that have not cleared after multiple attempts at different types of therapy, where no medication is involved.
If you feel that you have treatment-resistant depression or would like to talk about any of my services, please feel free to contact me or schedule a consultation. The following provides an overview of therapy for treatment-resistant depression.
Treatment-Resistant Depression Overview
Here are some key points about TRD:
Definition and Criteria of Refractory Depression
TRD is typically defined by the lack of response to therapy and two or more antidepressant medications, each given at an adequate dose for an adequate duration (usually 4-6 weeks per medication). Some people expand the criteria to include people who try two or more different types of psychotherapy. People with TRD often have more severe and longer-lasting symptoms compared to those whose depression responds to initial treatments.
Potential Causes of Treatment-Resistant Depression
Genetic predispositions, such as those that cause neurotransmitter imbalances, are often involved with treatment-resistant depression. Sometimes, psychosocial factors such as chronic stress, traumatic experiences, and inadequate social support are involved as well. In some cases, co-existing medical conditions such as thyroid disorders, chronic pain, or substance abuse can complicate the treatment of depression.
Other potential causes of refractory depression include other mental health disorders such as anxiety, bipolar disorder, personality disorders, or substance abuse. Even if they don’t cause it they can generally make depression harder to treat. Isolation or lack of supportive relationships can worsen depression. Finally, for some, poor diet, lack of exercise, and other unhealthy lifestyle choices can contribute to the persistence of depression.
Understanding the multifaceted causes of refractory depression can help us develop the most effective treatment strategies tailored to your needs. That said, sometimes the reasons for the symptoms remain elusive, yet we can still find solutions that reduce or eliminate them.
Therapy for Treatment-Resistant Depression
Psychotherapy can help treat TRD, with the following techniques being the most commonly used:
- Cognitive-behavioral therapy (CBT), which focuses on changing negative thought patterns and behaviors, is often the first choice for treatment-resistant therapy.
- Dialectical Behavior Therapy (DBT), which was originally developed for borderline personality disorder, combines CBT with mindfulness and is effective for the emotional regulation difficulties that people often experience with TRD.
- Interpersonal Therapy (IPT) is a great choice as a therapy for treatment-resistant depression when improving relationships and social functioning is a major goal.
- Psychodynamic Therapy explores unconscious processes and past experiences affecting current behavior and emotions, so it is a good choice when events from the past are potentially causal.
Adjunctive Treatment Strategies
- Medication Adjustments: Switching to different antidepressants, combining medications, or using augmentation strategies (adding a non-antidepressant medication that can enhance the effects of antidepressants) can help with TRD.
- Repetitive Transcranial Magnetic Stimulation (rTMS): This non-invasive procedure uses magnetic fields to stimulate nerve cells in the brain. I am not an expert in this method, so you should start with your primary care physician to inquire about this.
- Ketamine and Esketamine: Ketamine, traditionally an anesthetic, and its derivative esketamine have shown rapid antidepressant effects in some TRD patients. You should also speak to your primary care physician if you are thinking or pursuing this route.
Medication Adjustments
The following are some ways to target TRD, but I would suggest each should be done in conjunction with therapy for treatment-resistant depression. This is why I work closely with several psychiatrists.
- Switching Antidepressants: Trying different classes of antidepressants.
- Combination Therapy: Using multiple antidepressants together.
- Augmentation Therapy: Adding non-antidepressant medications (e.g., antipsychotics, mood stabilizers, or thyroid hormones) to enhance the effects of antidepressants.
Management and Support
Integrated approaches involving psychiatrists, psychologists, primary care providers, and other specialists can be effective, and I often follow a team approach to treatment. I also encourage support from family, friends, and support groups. Here are some supportive approaches:
Lifestyle and Complementary Therapies
Often, lifestyle changes are not adequately considered when traditional therapies are tried. Thus, treatment-resistant depression therapy is frequently augmented by complementary techniques and approaches, such as:
- Exercise: Regular physical activity can help alleviate symptoms of depression.
- Mindfulness and Meditation: Techniques such as mindfulness-based cognitive therapy (MBCT) can help reduce depressive symptoms and prevent relapse.
- Nutrition: Dietary changes and supplements (e.g., omega-3 fatty acids) may support overall mental health.
- Sleep Hygiene: Addressing sleep disorders and maintaining good sleep habits can improve mood and overall well-being.
Integrative and Holistic Approaches
Holistic therapy for treatment-resistant depression can be quite helpful in magnifying the effects of psychotherapy for some people. The following have been shown to help in many cases:
- Acupuncture: Some evidence suggests it may help alleviate depression symptoms.
- Yoga and Tai Chi combine physical movement, meditation, and breathing exercises to reduce stress and improve mood.
Supportive Therapies for Refractory Depression
While many people consider couples and family therapy as exclusively for people who need to work something out as a pair of family group, these approaches can also be helpful when only one member is suffering. The others want to know how to best support them.
- Support Groups: Sharing experiences and coping strategies with others facing similar challenges can provide emotional support.
- Couples Therapy: Involving your partner in your treatment can be quite helpful so that they can learn how to support you best.
- Family Therapy: Involving family members in treatment can improve communication, support, and understanding.
Therapy for Treatment-Resistant Depression in My Practice
I continually follow the ongoing research that attempts to understand the biological mechanisms underlying TRD, identify biomarkers for predicting treatment response, and develop new therapeutic options. This leads me to adjust my integrated treatment approach. Therapy for treatment-resistant depression requires a personalized and often multi-faceted treatment approach, and I collaborate with all other providers you may have. Continuous monitoring and adjustment of therapies are crucial to finding the most effective treatment for each client with TRD, and we’ll work together to find the best approach for you.
Example of Refractory Depression Treatment
Sara is a 35-year-old teacher who was diagnosed with major depressive disorder at age 28. She has no significant physical health issues, was reasonably happy before the diagnosis, and has some family history of dysthymia.
Refractory Depression History
When she was first diagnosed, she was started on a selective serotonin reuptake inhibitor (SSRI) called Escitalopram 20 mg/day. She also had Cognitive-behavioral therapy (CBT) once a week. Unfortunately, she showed minimal improvement after 12 weeks, and her depressive symptoms persisted. Then she changed to a different type of medication called a serotonin-norepinephrine reuptake inhibitor (SNRI), Venlafaxine 150 mg/day. A new treatment approach, weekly sessions of interpersonal therapy, was started. This time, she experienced some improvement in her mood, but significant depressive symptoms remained.
More recently, Sara’s psychiatrist started her on an atypical antipsychotic – Aripiprazole 5 mg/day. A new CBT course involved different strategies and a mixed approach with some humanistic techniques. Again, she saw a slight improvement but was still experiencing severe depressive episodes. She is the same as me, with persistent feelings of sadness, hopelessness, fatigue, difficulty concentrating, and recurrent thoughts of death. She is struggling with daily activities and maintaining work responsibilities. Sara clearly has refractory depression, as she has not achieved sustained remission despite multiple treatment strategies over several years. Her ongoing struggle highlights the need for further evaluation and consideration of alternative treatments.
Refractory Depression Treatment
I agreed to see Sara in my integrated practice to try new approaches. I referred her to a psychiatrist I work closely with, and she prescribed Phenelzine, a monoamine oxidase inhibitor, that is in a different class than the ones she’s tried. I initiated schema therapy, which is quite different from what she’s tried. It focuses on identifying and changing deeply ingrained patterns. It is considered a good choice for those with Refractory Depression. I paired that approach with closely related Narrative Therapy. Sara began to have some improvement in coping mechanisms and a reduction in negative thought patterns.
We also focused on lifestyle changes, which had not previously been part of her treatment. She undertook a personalized fitness program, including aerobic and strength training exercises, aiming for 30 minutes five days a week. She also consulted with a nutritionist to ensure a balanced diet rich in omega-3 fatty acids, vitamins, and minerals. Finally, I taught her mindfulness techniques to reduce stress and improve emotional regulation.
Another new approach was to involve her family who would provide support and improve communication. They would join our sessions once a month, and Sara and I would tell them how they could help support her. She also joined a reputable online peer support network for individuals with refractory depression.
Monitoring and Follow-Up
I give Sara a monthly normed questionnaire to monitor her symptoms, side effects, and overall progress. We will adjust psychotherapy approaches and other treatments based on these results. Sara’s comprehensive treatment plan incorporates a variety of advanced and holistic approaches to address his refractory depression. This multi-faceted strategy aims to provide sustained relief and improve her quality of life through careful monitoring and adjustment of treatments.
Treatment-Resistant Therapy Referrals
My psychological practice is integrative, meaning I mix different clinical approaches to give you the best outcome. This can be helpful as therapy for treatment-resistant depression often needs to evolve as symptoms change. I would be happy to help you gather information about refractory depression and the options you have. Please feel free to contact me or schedule a consultation to discuss this further.
