So what about medications? In general, medications are effective for treating problems with sleep, energy, and concentration, but they are slower to affect negative thoughts, which may be why CBT is a good complement to antidepressants. Make sure you have a long enough trial of a given medication, at a high enough dose. Some people believe they are treatment resistant, but it may be that they have not had a good trial of medications with adequate dosing.
If the first medication you try doesn’t work, the choice is then to switch medications or to add another medication to your regimen. Initially, most people switch to another medication, but then their treatment provider may start augmenting their medication with agents that have been tested for this purpose, like lithium or thyroid hormone. Combinations of antidepressants can work for some people, but there are few studies in this area. Some case reports indicate that atypical antipsychotics may help as well. Talk with your doctor and consider getting a referral to an expert in this area. Make sure to make a complete history of the therapies you have tried – medications and other treatments – for your visit. This will help the expert give you better advice.
If you truly have treatment-resistant depression and have failed multiple trials of medications, then vagus nerve stimulation (VNS) may be an option. This is a new FDA-approved treatment that involves a device implanted under one’s skin. I have no clinical experience with VNS, but I know that new approaches are clearly needed for the debilitating and sometimes lethal condition of depression. VNS has been used successfully and safely for years in seizure patients, so we know that its risks (such as coughing or irritation at the site of the implant) are transient and usually manageable.
The early studies on the effectiveness of VNS show promise, but more experience and study will help us better understand who will benefit most from this novel approach to an age-old problem. I’d recommend reviewing such a decision with a psychiatrist who is well aware of this treatment device and who can be sure you have received good care for your medication trials before embarking on this novel strategy.
Ken Duckworth has no financial relationship to VNS device manufacturers, pharmaceutical companies, or to the publishers of manuals or texts noted in this column.
Printed in the Winter 2006 Issue of NAMI Advocate. Reprinted with permission from The National Alliance on Mental Illness (NAMI), www.nami.org
