Ask the Doctor: Treatment-Resistant Depression

It is frustrating for all involved when someone does not respond to treatments for depression that work for most other people. But we can't accurately predict who will respond to a particular intervention, and some will be in the group called the "non-responders." Calling them "non-responders" almost sounds like we are blaming them for not getting better, doesn't it? Let's not blame these people, but rather review some strategies to address treatment-resistant depression and discuss a novel treatment has come down the pike.

When clinical (or major) depression, about 20 percent to 30 percent of people do not respond to treatment. We don't know why; this is just the state of the field right now. The first thing I encourage people to do when they have not responded to treatment is to review the basics of their care, aside from medications. The foundations of self-care - aerobic exercise, eliminating toxic stressors, building supportive relationships, getting enough rest, and a healthy diet - are essential. If your thoughts are persistently negative, give cognitive behavioral therapy (CBT) a good trial in addition to your medicines. If there is not a CBT practitioner in your area, Feeling Good: The New Mood Therapy, by David Burns, M.D., is a classic guide with easy-to-read descriptions of CBT. Most studies show that combining talk therapy like CBT together with medications produces a better result than either treatment alone.

If your depression persists, think about other possible causes - could you have a medical problem like hypothyroidism that could explain it? This condition can be detected with a simple blood test. Could other medications you take be contributing to your depression? This is a common problem with beta blockers for high blood pressure, and also with some treatments for Parkinson's disease. Alcohol can also complicate a depression picture, so attention to sobriety can be crucial.

There are also many subtypes of depression. For example, people with bipolar depression often have atypical symptoms - such as sleeping more and eating more - and this is a challenge to treat. Seasonal depression in winter can add to the picture, and light therapy can be helpful for that. Depression with psychotic features typically responds very well to electroconvulsive therapy, or ECT, also known as shock therapy.

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),