Three years ago I began taking antidepressants. They have not worked for me. It’s been a rollercoaster ride trying different medication. At times, I feel empty and hollow. But there are also moments when I feel better. But I still have not found the right treatment. This is because my treatment-resistant depression (TRD) is not a DSM diagnosis, but it is real.
It is exactly what you would expect treatment-resistant depression to sound like. Patrice Douglas is a therapist who’s pursuing her PsyD. “Treatment resistant depression” refers to a condition in which standard treatments, like medication and talk therapy, fail to relieve depression symptoms. Although the symptoms may be similar, different treatment options might be required.
When depression doesn’t respond well to conventional treatment options, such as medication or lifestyle modifications, experts usually consider it treatment-resistant. Carlene MacMillan MD, founder and CEO of Brooklyn Minds Psychiatry adds that although the number of antidepressants used varies depending upon who you use, it’s usually two to three antidepressants taken in sufficient quantities for several weeks. Although the symptoms may be similar to regular depression, the treatment response can often be worse.
Experts explain how depression might resist treatment and what we can do to help someone who is going through it.
What makes depression so difficult to treat?
There is a culture-based understanding of depression, a disorder of the mood that can lead to feelings of sadness, hopelessness and apathy. Some people may even think of self-harm. However, there aren’t universal treatments that work for everyone. Douglas says that what works for one individual may not work well for the other. She says that while medications can be beneficial, sometimes it takes a long time to identify the best ones for a patient. She notes that this involves trying out different medication and giving the patient time to evaluate efficacy. It can take several months.
Although talk therapy is often life-changing and can make a huge difference in someone’s lives, there are times when it may not be the best option. Douglas states that while talk therapy remains the most common approach to mental health issues, there are many other therapies available that can be beneficial. Talk therapy may not be sufficient to meet someone’s needs. One can also try art therapy or equine treatment, as well as dialectical behavioral therapy. This takes some time.
TRD may also be caused by an incorrect diagnosis and therefore the wrong medication. Douglas states that depression can be caused by many different things. It could be bipolar disorder or another similar disorder, which requires a mood stabilizer rather than an antidepressant. TRD can occur in clinical practice with as many as 60% not receiving adequate treatment.
The fact that SSRI or SNRI antidepressants work slowly is another factor. Dr. MacMillan says that there are many genetic factors involved in depression. Some people respond better to certain medications than others. Depression is not always a one-off event. Depression may be more challenging to treat for people with other mental disorders like personality disorders and substance abuse disorders.
TRD can also be caused by lifestyle and personal history factors such as alcohol consumption and poor sleep hygiene. TRD can be exacerbated by depression. JoAnn Yanez (ND, MPH), CAE is the Executive Director of the Association of Accredited Naturopathic Medical Colleges. She says that some patients do not respond well to traditional approaches if they are not treated or if there are other underlying causes. I have treated patients who had unresolved traumas, hormonal problems, stress management issues or life situations. They can be resolved partially or fully if they are addressed properly.
How can you help TRD?
It can be difficult to look after yourself when you feel down. However, sleep, exercise, and eating are key components of feeling well. These can all be part of a holistic approach that includes medication and therapy for depression. Dr. Yanez says, “Care should be taken to make sure you are eating a colorful, whole-foods based diet rich in omega fatty acids, protein and antioxidants.” Removing simple sugars/carbohydrates, caffeine and alcohol can also be helpful. Regular exercise, whether it is vigorous or walking, has been shown to improve mood and control blood sugar. Supplements like magnesium, B vitamins, and neurotransmitter precursors such as St. John’s Wort or lavender, can be helpful for some. However, it is important that patients consult a licensed Naturopathic Doctor to determine the best treatment plan.
It is important to find a qualified care provider who has experience treating people suffering from treatment-resistant depressive disorder. Fraga suggests psychodynamic and trauma-informed therapy for treatment. She says that in some cases of TRD, childhood trauma or early trauma can be the root cause. Psychodynamic and trauma-informed psychotherapy helps to address these traumas.
Dr. MacMillan suggests that you seek out a specialist in TRD if you are taking medication. She says that transcranial magnet stimulation, esketamine, Spravato, MAOIs such as the EMSAM patches, and electroconvulsive treatment for severe cases of depression are all FDA-approved, evidence-based treatments. OptionsMD is a program that connects people suffering from treatment-resistant depressive disorder to the appropriate programs and treatments. There are clinical trials available for treatments such as psilocybin (a psychedelic medication), which could open the door to even more possibilities.
Again, patience is important. Douglas says that sometimes it can take a while for people to adjust to medication and therapy. Douglas also recommends sharing your medical history with your team to help them determine the most effective treatment. Douglas suggests that you keep a daily mood diary to record how your day is going. This will benefit your treatment team as well as your self. Although you may not feel better immediately, your mood journal can help to increase motivation.
Dr. Yanez says that people suffering from treatment-resistant depression need to look at the root causes of their depression. Naturopathic doctors understand that depression can be a sign. It is the body’s way to let us know that something is wrong.” She suggests people examine their stress response and look into mindfulness, which can be helpful in managing stress.
Dr. Yanez states that natural therapies are a useful tool when used under supervision of a licensed and trained naturopathic physician. There are fundamental principles to help our bodies and minds stay healthy. Each of these treatments may prove beneficial on its own, or in combination. We encourage our patients to see a licensed Naturopathic Doctor, particularly if they’re on prescription medication. Some supplements may be contraindicated when taken with prescribed drugs.
What you can do to support someone suffering from TRD
People with depression need to have social support. This can be in the form of professional counselors, coaches and medical teams. But friends and families can help those they love. Dr. MacMillan says that depression is a serious medical condition. It can cause frustration and unpredictable behavior for everyone involved. Dr. MacMillan says that depression is a medical illness and can be unpredictable and frustrating for all involved.
Douglas advises that you have patience if someone close to you is suffering from depression. One person might have depression for many months or even years, but that does not mean they don’t want to improve their lives. She says, “Accept the fact that they may still be struggling even with treatment.” You can help by getting involved in the treatment. Let them know that they are able to talk to you about medications, drive them to therapy and even cook for them. You can make sure they stay on the right track by getting involved. She suggests that you should always be a part of a team. Family members and friends of people with depression should also know they are not alone. Dr. MacMillan says that the National Alliance on Mental Illness and Depression and Bipolar Support Alliance have both online and local chapters which offer support to loved ones.
It makes me feel optimistic that I am not the only one suffering from TRD. There are many treatment options available. It can be difficult to get better, and it can take some time.