There’s hope for treatment-resistant depression

A man with depression opening the curtains in the morning

If you’re struggling with depression, the goal of treatment is to get you back to your baseline level of functioning — back to your usual self. We do that with psychotherapy and medications. But if you’ve tried multiple antidepressants of different classes at therapeutic doses, for at least six to eight weeks each, and you’re still struggling, you may have treatment-resistant depression.

You also may have difficult-to-treat depression if you continue to have symptoms of depression or have multiple episodes of depression despite adequate treatment.

Approximately 30% of patients with depression have treatment-resistant depression, or TRD.

But there is light at the end of the tunnel. A number of interventional treatments can help address TRD. All are used in addition to antidepressants and have been shown to be effective.

Treatment-resistant depression options

Electroconvulsive therapy

Electroconvulsive therapy (ECT) is still considered the gold standard for TRD and is highly effective. ECT is administered while you’re under anesthesia to induce a seizure. Patients generally recover within an hour, without any significant negative effects. Because ECT carries a stigma for some people because of representations in historical media, we work to educate patients on how much it has changed over the past several decades, like many other medical interventions. We offer materials that show a true depiction of what treatment looks like today, with sophisticated machines to deliver ECT and safer medications to prepare patients for the procedure. According to the National Institute of Mental Health, 80% to 90% of people with severe depression improve dramatically with ECT.

Transcranial magnetic stimulation

Transcranial magnetic stimulation (TMS) uses magnetic pulses to stimulate areas of the brain that control mood and anxiety, which are underactive in patients experiencing depression.

Sessions last less than an hour and are typically scheduled five days a week for approximately six weeks. Patients are awake and alert during treatments and can resume normal activities upon leaving therapy.

Intravenous ketamine infusion

Intravenous ketamine infusion (KET) is used for refractory patients who have failed other treatment modalities. IV ketamine is best known as an anesthetic agent during surgery and is approved by the U.S. Food and Drug Administration for that use. Because it’s not FDA approved for treating depression, use is considered off-label and often isn’t covered by insurance. Because of long-term safety concerns, psychiatrists use this treatment for selective patients. Data has shown that ketamine helps with mood and suicidal thoughts.

Connect with the 988 Suicide and Crisis Lifeline 24/7 by calling or texting 988

Intranasal esketamine treatment

Intranasal esketamine treatment, known by the brand name Spravato, is a form of ketamine administered by nasal spray. It was recently approved by the FDA as an augmenting medication for treatment-resistant depression. The medication is usually self-administered under the supervision of a health care professional as part of a risk evaluation and mitigation strategy program. The patient is then monitored for two hours for side effects, which could include increased blood pressure and heart rate, nausea, dizziness, headache, sedation, dissociation and hallucinations.

Vagus nerve stimulation

Vagus nerve stimulation (VNS), recently available at the Ohio State Psychiatry and Behavioral Health interventional treatment program, delivers timed electrical signals to change brain wave patterns. Before administering this therapy, physicians implant an adjustable pulse generator in the chest. It connects to a wire that’s threaded beneath the skin and wound around the left vagus nerve. This alters brain activity to treat depression and other conditions, like epilepsy.

ECT, TMS and KET therapies all include an acute series of more frequent treatment, sometimes followed by less frequent maintenance treatment if needed. Some patients may need an additional series, but the treatments aren’t used on an ongoing basis. Patients need to continue their medications and engage in psychotherapy to maintain benefits and prevent relapse.

The therapy you choose might be based on your initial diagnosis, your other medical issues and medications and side effects. However, if one treatment isn’t successful, other options can be explored to attain resolution of depressive symptoms.

For patients whose depression improves, stopping these therapies following an acute or maintenance series can be discomforting, but it’s important to note that they do have some long-term benefits. While we’re not sure yet how long these benefits last, the therapies not only reset chemical imbalances in the brain, but they also change brain cell or synaptic connections.

Patients can also participate in relapse prevention therapy, which involves supplementing these benefits with psychotherapies, such as interpersonal therapy, biofeedback, behavior activation therapy, cognitive behavioral therapy (CBT), mindfulness-based cognitive therapy (MBCT) and dialectical behavior therapy (DBT). The patients can also participate in clinical trials and research exploring novel treatments in the area of TRD.

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