David Baxter PhD
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Treatment-resistant depression: Explore options when depression doesn't get better
By Mayo Clinic Staff
Aug. 27, 2009
Sometimes depression doesn't get better, even with treatment. Explore why this sometimes happens and what you can do about it.
If you've been treated for depression but your symptoms haven't fully improved, you may have treatment-resistant depression. Medications and psychotherapy work for most people. But with treatment-resistant depression, standard treatments don't help much or don't help at all. With treatment-resistant depression, symptoms ? such as feeling sad, hopeless and disinterested in activities ? persist despite treatment. Or, your symptoms improve only to keep coming back. Treatment-resistant depression can range from mild to severe, and generally requires trying a number of treatments to find out what works.
Use this guide to explore reasons why your depression treatment may not be working and options you might want to consider.
What causes treatment-resistant depression?
Like other types of depression, treatment-resistant depression is most likely caused by a combination of inherited and environmental factors that affect brain chemicals called neurotransmitters. A number of things can contribute to treatment-resistant depression, including:
Who should treat treatment-resistant depression?
Your family doctor can prescribe antidepressants and give you advice. But if your depression symptoms continue despite treatment, you should see a medical doctor who specializes in mental health (psychiatrist). You may also need to see a psychologist or other mental health counselor. It can be helpful if all of the mental health providers involved in your treatment communicate and work together.
What is the goal for treating depression?
Even though you may find a treatment that's somewhat effective at relieving your symptoms, keep trying to find the best treatment possible. People who find treatment that completely relieves symptoms are less likely to have a relapse of their depression later. That's why it's important to be patient and not settle for a treatment that isn't fully effective. Also, keep trying different treatments if your current treatment causes significant side effects.
What are the medication strategies?
Even if you've already tried antidepressants or other medications for depression and they didn't work, don't lose hope. You and your doctor simply may not have found the medication or combination of medications that works for you. You have several options even if you've tried medications in the past:
For some people with depression, psychotherapy works as well as medication. The combination of medication and psychotherapy is generally the most effective approach. If you're seeing a psychologist or other psychotherapist and it doesn't seem helpful, consider seeing someone else who has a different approach. As with medications, sometimes it takes several tries before you find out what works.
Many types of psychotherapy are used to treat depression. They include:
If standard depression treatment with medications and psychotherapy haven't been effective for your treatment-resistant depression, you may wish to consult with a psychiatrist who specializes in treatment-resistant depression to discuss these additional treatment options:
By Mayo Clinic Staff
Aug. 27, 2009
Sometimes depression doesn't get better, even with treatment. Explore why this sometimes happens and what you can do about it.
If you've been treated for depression but your symptoms haven't fully improved, you may have treatment-resistant depression. Medications and psychotherapy work for most people. But with treatment-resistant depression, standard treatments don't help much or don't help at all. With treatment-resistant depression, symptoms ? such as feeling sad, hopeless and disinterested in activities ? persist despite treatment. Or, your symptoms improve only to keep coming back. Treatment-resistant depression can range from mild to severe, and generally requires trying a number of treatments to find out what works.
Use this guide to explore reasons why your depression treatment may not be working and options you might want to consider.
What causes treatment-resistant depression?
Like other types of depression, treatment-resistant depression is most likely caused by a combination of inherited and environmental factors that affect brain chemicals called neurotransmitters. A number of things can contribute to treatment-resistant depression, including:
- Emotional stress. If you're feeling stress or anxiety because of situations in your life that aren't getting better, medications alone might not help. Examples include relationship issues, financial problems or inadequate housing. In addition, childhood abuse or neglect can continue to affect you throughout adulthood. Psychotherapy can be especially helpful in coping with stressful situations.
- Not taking medications exactly as prescribed. Treatment may not work if you stop taking your medication, skip or lower a dose, or forget to take a dose. Many people get off track. This can happen for a number of reasons, including problems with side effects, thinking you don't need medication or that you don't need a full dose of medication because you feel better, or simply forgetting. If you do stop taking your medication, forget to take a dose or make other changes, be honest with your doctor about it so that you can address any problems and get back on track.
- Underlying health problems. Other medical conditions or illnesses can sometimes mimic or worsen depression. These include thyroid disorders, chronic pain, anemia, heart problems, anxiety disorders, and substance abuse or addiction.
- Another mental health diagnosis. It's not always easy to diagnose depression, and other mental health disorders may require different treatment. In particular, some forms of bipolar disorder are commonly misdiagnosed as depression if manic phases are mild. In many cases, depression occurs along with other conditions ? such as panic disorder or post-traumatic stress disorder ? which can make depression more difficult to treat. Ask your mental health provider whether your symptoms may be caused by bipolar disorder or linked to another mental health condition.
Who should treat treatment-resistant depression?
Your family doctor can prescribe antidepressants and give you advice. But if your depression symptoms continue despite treatment, you should see a medical doctor who specializes in mental health (psychiatrist). You may also need to see a psychologist or other mental health counselor. It can be helpful if all of the mental health providers involved in your treatment communicate and work together.
What is the goal for treating depression?
Even though you may find a treatment that's somewhat effective at relieving your symptoms, keep trying to find the best treatment possible. People who find treatment that completely relieves symptoms are less likely to have a relapse of their depression later. That's why it's important to be patient and not settle for a treatment that isn't fully effective. Also, keep trying different treatments if your current treatment causes significant side effects.
What are the medication strategies?
Even if you've already tried antidepressants or other medications for depression and they didn't work, don't lose hope. You and your doctor simply may not have found the medication or combination of medications that works for you. You have several options even if you've tried medications in the past:
- Trying a medication longer. Antidepressants and other medications for depression typically take four to eight weeks to become fully effective and for side effects to ease up. For some people, it takes even longer for medication to work, so it helps to be patient.
- Increasing your dose. Because people respond to medications differently, you may benefit from a higher dose of medication than is usually prescribed. Discuss with your doctor whether this is an option for you. Don't alter your dose on your own.
- Augmentation. Augmentation means taking an antidepressant along with a medication generally used for another mental health condition. It may take some trial and error since there are numerous medications for use in augmentation, including anti-anxiety medications, anti-seizure medications, mood stabilizers, beta blockers, antipsychotics and stimulants. The downside of augmentation is that some of these medications may cause bothersome side effects or require periodic blood tests.
- Switching. Switching to a new medication is common when an antidepressant doesn't work effectively. Each person responds to medications differently. In nearly 1 in 3 people, the first antidepressant tried doesn't work at all. You may need to try several antidepressants before you find one that works. You may switch from one antidepressant to another in the same class. Or, you may switch from one class of antidepressants to another.
- Combination. In the combination approach, different classes of antidepressants are prescribed at the same time. That way they'll be more likely to affect a wider range of brain chemicals that affect mood. For instance, you may take both a selective serotonin reuptake inhibitor (SSRI) and a norepinephrine and dopamine reuptake inhibitor. Or you may combine an older antidepressant such as a tricyclic antidepressant with an SSRI. Regardless of the specific medications, the goal is to target several kinds of neurotransmitters at once, including dopamine, serotonin and norepinephrine.
- Taking L-methylfolate. This prescription supplement provides a form of the B vitamin folic acid, which is necessary for the production of neurotransmitters in the brain linked to mood. Taking this supplement may help with depression if you lack the enzymes to properly break down folate from foods or from standard folic acid supplements.
- Having the cytochrome P450 (CYP450) genotyping test. This test checks for specific genes that affect how your body uses antidepressants. It can help predict whether your body can or can't process (metabolize) a medication. This may help identify which antidepressant might be a good choice for you. There is some evidence that other tests for certain genes that regulate the neurotransmitter serotonin may help predict if you're likely to respond to a serotonin antidepressant. These genetic tests aren't widely available, so they're only an option for people who have access to a clinic that offers them.
For some people with depression, psychotherapy works as well as medication. The combination of medication and psychotherapy is generally the most effective approach. If you're seeing a psychologist or other psychotherapist and it doesn't seem helpful, consider seeing someone else who has a different approach. As with medications, sometimes it takes several tries before you find out what works.
Many types of psychotherapy are used to treat depression. They include:
- Cognitive behavioral therapy. This type of counseling addresses thoughts, feelings and behaviors that affect your mood. It helps you identify and change distorted or negative thinking patterns and teaches you skills to respond to life's challenges in a positive way.
- Interpersonal psychotherapy. Interpersonal psychotherapy focuses on resolving relationship issues that may contribute to your depression.
- Family or marital therapy. This type of therapy involves family members or your spouse in counseling. Working out stress in your relationships can help with depression.
- Group psychotherapy. This type of counseling involves a group of people who struggle with depression working together with a psychotherapist.
- Psychodynamic treatment. The aim of this counseling approach is to help you resolve underlying problems linked to your depression. This type of treatment can take longer than other types of psychotherapy because it involves exploring your feelings and beliefs in-depth.
If standard depression treatment with medications and psychotherapy haven't been effective for your treatment-resistant depression, you may wish to consult with a psychiatrist who specializes in treatment-resistant depression to discuss these additional treatment options:
- Electroconvulsive therapy (ECT). In ECT, electrical currents are passed through the brain to trigger a seizure. Although many people are leery of ECT and its side effects (such as confusion or amnesia), it typically offers immediate relief of even severe depression when other treatments don't work.
- Vagus nerve stimulation. This treatment uses electrical impulses with a surgically implanted pulse generator to affect mood centers of the brain.
- Transcranial magnetic stimulation (TMS). With this treatment, magnetic fields are used to alter brain activity. A large electromagnetic coil is held against your scalp near your forehead to produce an electrical current in your brain.
- Katon W, et al. Treatment of resistant depression in adults. UpToDate Inc.
- Matthew SJ. Treatment-resistant depression: Recent developments and future directions. Depression and Anxiety. 2008;25:989.
- Carvalho AF. Augmentation strategies for treatment-resistant depression. Current Opinion in Psychiatry. 2008;22:7.
- Stahl SM. Novel therapeutics for depression: L-methylfolate as a trimonoamine modulator and antidepressant-augmenting agent. CNS Spectrums. 2007;12:739.
