Treatment Resistant Depression

Treatment Resistant Depression Frank Barnhill M.D.

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The term treatment resistant depression refers to the clinical state occurring when you are being treated for depression, yet your response to that therapy is less than adequate or what you want or expect. In other words, you’re not getting better even though you are taking the drugs or going to counseling!

To understand how we decide whether your depression has become resistant to medications or treatment, we must first discuss how we would know when therapy is actually working in the first place. So, let’s take a look at what guides my assessment of whether a depressed person is responding to therapy or not.

My therapy goals for patients treated for depression include:

- you reaching a stable emotional state

- feeling you are no longer depressed at least 70% of the time or

- feeling your depression is now only a minor part of life

- having feelings of more security

- feeling as if you are back to your old self most of the time

- having a sense of being in control of your well being

- sensing and displaying more energy

- showing better levels of concentration

- having better relationships with family and friends

- showing signs of enjoying life and your family

- being able to plan for your future without anxiety or dread

- improved work skills and handling stress at work effectively

All of us have experienced setbacks and both big and little disappointments in life.

However, we usually are able to handle those ups and downs we have come to expect. But, when it comes to those of us who are suffering depression, even the littlest stresses in life can cause a person who has been doing well with their depression to suddenly develop treatment resistance.

Let’s just take a look at a few of the most common reasons for depression to suddenly worsen for adults:

- pregnancy and the stress of a newborn child

- losing control of what you normally do at home or work

- divorce or marital problems

- loss of a job or financial problems

- loss of a loved one

- new responsibilities at work or working longer than usual hours

- stopping a regular exercise program abruptly

- not taking your medications every day or skipping days

- abusing caffeine, alcohol or other chemicals or drugs

- excessive use of over the counter herbal remedies and supplements

- losing emotional support from your family or spouse

- sudden onset of thyroid or other endocrine diseases

- a near death experience, such as a car wreck, heart attack, or hospitalization for pneumonia

The stressors or events that can cause worsening of depression in children are numerous and will be discussed in another article.

Now that we have discussed reasonable goals for therapy and the things that can cause treatment to partially or completely fail, let’s give you ideas about what to do to fix the problem.

Here are the steps you need to take right away:

First, discuss the problem with your doctor or therapist right away. Treatment resistant depression is a very difficult nut to crack and requires a high level of expertise to sort out and optimize therapy.

Second, tell your family what you suspect is happening. That way, you won’t alienate, upset or confuse them any further if that’s been happening and they will understand why they need to be more supportive of you in your battle with depression.

Third, if you are not already seeing a counselor or psychologist, it’s time. You should make arrangements through your family doctor right away. It is essential you have someone who is readily available, can listen to you without judging what you say, and then make suggestions on handling your problems.

A lot of depressed persons feel as if they are riding a non-stop roller coaster and can’t get off.

Good! You’ve made it this far without much effort. Now what can you expect your doctor to do to help matters get better? To give you an idea of how I help my patients, let’s take a look at my “resistant depression” problem solving protocol.

In order, I usually try to:

- identify the change that caused this person’s previously
treated depression to become resistant

- involve family and friends in finding that cause if necessary

- help the depressed patient build a support group and support mechanisms

- start working on caffeine, alcohol and drug use issues

- make a referral to a psychologist or Cognitive Behavioral Therapist (CBT)

- change current antidepressants to a new one in the same category of drugs

- see you back in one or two weeks and re-evaluate your situation

- if on the visit in two weeks you are clearly not improving, we’ll increase your medication

- I’ll probably see you back every two weeks until you feel you are stabilizing

- If at the end of 4 to 5 weeks, you still are not responding to that drug combined with CBT, it’s time to change to a totally different class of antidepressants

- If we make it into the ninth week and things still aren’t really good, then it’s probably time to add another drug, possibly one for manic depression or anxiety

- If we proceed much past this point and you’re not getting better, don’t be surprised if I ask you to allow me to consult a psychiatrist

Just a few closing notes:

- Treatment resistant depression can occur for no reason what so ever! This is the hardest type to sort out and treat. I’ve had patients that literally probed their lives looking for a cause and never found one! (The treatment is the same regardless!)

- You must have a thyroid test to evaluate this type of depression and if the test is even borderline in values, you and your doctor should discuss thyroid hormone replacement.

- Hormonal deficiencies other than thyroid disease cam also cause treatment failures. Hint: hot flashes, estrogen, menopause, erection problems, testosterone

- Treatment resistance may last for over a year before the right combination of medications and therapy is hit upon.

- Once your treatment resistant depression is under control, with no medication side effects, you should not allow any one (including your insurance) to change or modify it.

- It is extremely important that you continue to take your medications and attend counseling even after you think you have stabilized. The goal in depression therapy is to provide treatment to help you (the depressed person) reach a state of remission (back to your near normal or better than normal self) that is maintained for minimum one year before trying to decrease medications and CBT.

- Never abruptly stop an antidepressant without talking to your doctor, unless you have a severe reaction to it. Several of these drugs cause terrible side effects when stopped suddenly.

Another great sign! You’ve made it to the end of the article!

I’d like to emphasize that every one’s depression is totally different from another’s. We’re all very unique individuals and react differently to the same situations as others.

You need to ask your doctor or therapist to “custom fit” your depression therapy for greater success in helping you reach your greatest emotional and personal potential in life. He or she may not evaluate you or provide therapy in exactly the same manner as I, but alas that’s what makes the difference in doctors. Medicine is truly an art form to be practiced!

Dr. Frank

These health tips are offered for your common sense use and are not intended to take the place of a visit to your doctor. Your use of the materials implies your understanding that nothing herein contained represents individual medical advice.

drhuggiebear, drhuggiebear.com and contained materials are the copyrighted and/or registered properties of Frank Barnhill, M.D. and may not be reproduced for profit without the express written permission of the author. All materials may be photocopied in whole for educational use. For information please contact us at drfrank@drhuggiebear.com.

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