Treatment-Resistant Depression: What It Is and How to Manage It

Treatment-Resistant Depression: What It Is and How to Manage It

My room is dark; My darkness is over. What's next? What now? Why all this? Do I somehow deserve this? Why doesn't anything or no one help me? I don't want to feel like this anymore. An ashen haze surrounds me all day, every day, with long periods of darkness so interspersed that I even welcome gray. I'm so afraid it'll never be gray again - what then? I'm out of control in my head and in my heart; My feelings are so overwhelming and my thoughts so confused that it's a free fall into an abyss with no limits - only pain and fear; too much indecision, too much distraction without purpose; endless streams of helpless, hopeless jokes in an echo-filled head.

I read and was instructed not to “go gentle into that good night.” I fought so hard but it didn't matter. There's nothing gentle about that. It is unrelenting pain with no compassion and no identity – it is invisible. There is no fairness or reason - it just stops and swallows me - why?! What else can I do? What else can you do? What kind of plague is this?

Depression, particularly treatment-resistant depression, is an insidiously damaging disease. It can be subtle at first, but then it shows that it is like a parasite - a parasite that steals everything and wants to kill the host.

Depression is a treatable disorder. In most cases, standardized modalities are very effective in improving or even alleviating the disorder. But sometimes not so mildly – ​​this form is called treatment-resistant or refractory depression [TRD]. There are very small differences in the definition of TRD, but it is generally defined as: an inadequate response to one, [or at least two or more], antidepressant trials with appropriate doses and duration. Unfortunately, this is a relatively common occurrence (see Diagnosis and Definition of Treatment-Resistant Depression, M. Fava; March 8, 2017).

In clinical practice this is observed in up to 50 to 60% of cases. Subsequently, it is recommended to perform diagnostic re-evaluation of these patients to achieve better results. There are many potential contributing and confounding factors that may be involved and may not be initially obvious. Examples of medical conditions include Parkinson's disease, thyroid disease, stroke, COPD, heart problems, undetected substance abuse and significant personality disorders can be culprits. Other potential causes include comorbid psychiatric disorders such as anxiety, psychosis, early dementia, bipolar depression diagnosed as unipolar, trauma or abuse not initially identified, chronic pain, other drug interactions, and/or patient noncompliance. Identifying all of these potential variables is both essential and challenging for both the clinician and the patient. Collaborative historians are very valuable in shedding light on the issue, i.e. family, co-workers, teachers, etc. All of these individuals or groups would of course need the patient's permission for privacy reasons. Reliable psychosomatic rating scales can be helpful in identifying and, in some cases, quantifying the severity of the problem. There are different levels of resistance. Some respond easily to minor adjustments in treatment, others are much tougher.

Treatment options can include many different modalities. Usually the first level of alternative care is achieved by increasing the dose, changing or adding (augmentation) antidepressants or other non-antidepressant medications such as lithium, several atypical antipsychotics, stimulants or thyroid hormone. Again, appropriate doses and duration are required. Patients must first be able to tolerate the medications or combinations due to possible side effects or side effects, which always represent a potential risk.

The risks and benefits of any recommended medications should be discussed with patients before they are tried. The discussion should also include alternative therapies and/or possible outcomes if a patient forgoes recommended treatment. The patient must understand and then agree or disagree with the proposed treatment plan before it is started. This is the informed consent process.

In addition to other treatment modalities, electroconvulsive therapy (ECT) can be used safely for severe refractory depression or in patients with severe depression who cannot tolerate standard antidepressants.

Vagus nerve stimulation, transcranial magnetic stimulation, and other emerging methods of direct and selected brain stimulation have also been shown to produce effective results. The arsenal of successful treatment also includes ketamine IV infusion for resistant depression.

Psychotherapies of various types have been evaluated as effective and often necessary methods to support drug therapies in the fight against refractory depression. i.e. cognitive behavioral therapy, interactive-interpersonal, dialectical behavior and yes, even analytical in some cases, have been shown to be potentially effective. Treating remission, meaning no residual symptoms, must be the goal, otherwise recurrence is likely.

Outcomes for patients with TRD can vary widely. Relapse rates tend to be higher and faster in patients with TRD. It is important that these patients are evaluated and treated only by well-trained and experienced behavioral health professionals. This form of depression is certainly treatable. Hope and trust must be inherent in the treatment plan.

DON’T SUFFER ALONE…

Inspired by Charles Meusburger