Treatment Resistant Depression: Information, Symptoms, Treatment and More

Treatment Resistant Depression (TRD), also known as Refractory Depression, is a condition which involves a patient in the situation where their Depression hasn’t improved, despite various interventions.

There isn’t a set definition of TRD, however it is generally used for when a patient has failed to respond sufficiently to a range of talking therapies, as well as multiple antidepressants.

Unfortunately, treatments for depression don’t always work. Numerous failed attempts at treatment can leave an individual downhearted and hopeless.

However, there is still hope, and plenty of additional options exist. Like other forms of depression, recovery is possible.

What are the symptoms of Treatment Resistant Depression?

Treatment Resistant Depression affects people who have struggled to find an improvement for symptoms of Depression. Any sub-type of depression can turn into TRD.

Someone who has TRD will generally have tried a range of talking therapies, along with multiple antidepressants. Despite the multitude of treatment efforts, they may not have seen an improvement.

Like at the start of treatment, their symptoms will match those associated with other types of depression, such as:

• Low mood
• Hopelessness
• Low self-esteem
• Irritability
• Not finding enjoyment in life
• Sleep problems
• Suicidal ideation

As a result, it is normal for the individual to feel hopeless and wondering what to do.

What are the causes of Treatment Resistant Depression?

It isn’t known what causes TRD. Unfortunately, finding the right combination of treatment can take time.

This is especially true with antidepressant medication – it can take many different attempts before an effective one is found. Given there are several different antidepressants to try, there is no guarantee a patient will ever come across a medicine that suits them perfectly.

In some cases, people just simply don’t react to antidepressants at all. Talking therapies are similar – they might not work for some people.

However, there do appear to be some predictors. The patient may have an undiagnosed mental disorder that is running alongside their existing diagnosis of Depression. This is typically an Anxiety condition, or a Personality Disorder.

They may also have a physical health condition which is causing their symptoms – such as Hypothyroidism. If an individual has been misdiagnosed, they may not be taking the right medication for their symptoms. Past substance abuse may also be a risk factor [1].

In terms of the depression that precedes TRD, there are a range of potential causes. Traumatic or highly-stressful experiences often contribute to the condition, while many suggest a chain of events can cause a ‘downward spiral’ that results in depression.

Family genes, loneliness, substance abuse, childhood experiences (e.g. abuse or neglect), major illnesses and lifestyle can all contribute to depression. A chemical imbalance in vital neurotransmitters in the brain has also been put forward as a cause.

Diagnosis of Treatment Resistant Depression

If an individual has struggled to respond adequately to treatment, it is highly likely they are already in regular contact with a doctor or mental health professional.

The healthcare worker will normally realise that the individual is not responding well to treatment, and may be suffering from TRD.

As part of the diagnostic process, a blood test may be carried out, in case something else is causing the condition.

There isn’t a set number of talking therapies or antidepressants that need to have been tried in order for TRD to be diagnosed. However, conventional wisdom suggests that a minimum of 2 types of talking therapy and at least 3 different antidepressants should have failed to work in order for TRD to be diagnosed.

For example, a person may have tried talking therapies like Cognitive Behavioural Therapy and Interpersonal Therapy, but not found it helpful. Similarly, they may have tried antidepressants like Sertraline, Duloxetine and Mirtazapine – and not seen an improvement in symptoms.

There are a number of strategies though to try and provide an effective treatment, with the end goal of recovery.

How is Treatment Resistant Depression treated?

It is easy to think that after many different treatment plans have been tried, that there is no chance of a recovery. However, there are many other things that can be tried.

Talking Therapy

There are a huge range of types of talking therapies available. It might be the case that a person needs to try less conventional types of therapy:

Repetitive Transcranial Magnetic Stimulation (rTMS): Repetitive transcranial magnetic stimulation (rTMS) is a type of therapy that can be used to treat an array of mental health conditions. The therapy involves a trained therapist using a magnet in order to apply multiple magnetic pulses to the areas of the brain which are believed to be responsible for the regulation of mood and emotions – called neurotransmitters. In theory, the higher the level of these neurotransmitters, the better mood and emotions become. It is very rarely used as a first line treatment, but if someone has little success in lessening their symptoms with a range of other treatments, then rTMS may be used.

Mentalisation-based Therapy (MBT): MBT uses a range of techniques to try and help an individual understand themselves and their thoughts more. Mentalisation itself is the ability for an individual to think about thinking – essentially allowing an individual to examine their own thoughts, and the effect they have. MBT can help an individual understand what goes through the mind of others, as well as making an individual more aware of what happens in their own mind. This form of therapy is useful in various personality disorders.

Schema Therapy: Schema Therapy is a talking therapy that combines aspects of Cognitive-Behavioural Therapy, Gestalt therapy and psychoanalytical thinking into one form. It can be useful in treating personality disorders due to its ability to help people change longstanding patterns of thought and behaviour. The therapy is normally based on the idea that childhood needs were not met, leading to deeply-held obstructive beliefs. The therapist will attempt to change long-standing patterns that have contributed to problems, and can be very useful. Schema therapy is mainly intended for use in the treatment of personality disorders.

There are many ways that talking therapy can help. We have more information on our Therapy section.

Medication

Dosage Increase

While this may seem too simplistic, it is possible that in cases where an antidepressant isn’t having an impact, the dose may be too low.

Therefore, it could be worth taking an antidepressant that was well tolerated by the individual, and raise the dose to a higher level than before.

Augmentation

Probably the most common route is to augment an antidepressant with a new medication. Sometimes, antidepressants from two different classes can be co-administered.

For example, doctors often prescribe the atypical antidepressant Mirtazapine alongside a common selective serotonin reuptake inhibitor like Sertraline or Citalopram. Agomelatine is another augmentation medicine that can be used.

Away from antidepressants, the mood stabiliser Lithium is commonly used alongside an antidepressant. Antipsychotics, albeit in a low dose, can also be used as an adjunct, though only a few of these medicines are licensed for use in this manner.

The thought behind this is that by combining medicines that work on different areas of the brain, in theory there is a better chance of success. It is unlikely a GP will be able to prescribe an augmentation medicine, instead a specialist will probably do so.

Switching medication class

As mentioned earlier, it can take several different medicines to be tried before an effective one is found. A different class of Antidepressant could also be tried.

For example, two medicines called Vortioxetine and Vilazodone are becoming popular medicines for TRD [2]. Older Tricyclic antidepressants like Imipramine or an Atypical antidepressant like Reboxetine can also be tried.

There is a surfeit of potential antidepressants that can be tried. Of course, this is a very time-consuming method, and is rarely therefore suitable for someone who is suffering from TRD. In any case, it can still be attempted.

Other

Electroconvulsive Therapy (ECT): Electroconvulsive Therapy (commonly referred to as shock treatment) is a treatment that sees an electric current sent through the brain of an individual. The aim is to trigger an epileptic seizure, with the ultimate objective to relieve symptoms of a mental health problem. The human body is fully restrained during the procedure, which also involves a general anaesthetic. Electroconvulsive therapy is normally a last resort. Despite this, ECT actually has an impressive efficacy rate, with many people finding it helps immeasurably.

If more conventional treatments haven’t worked, there are also some alternative and complimentary treatments that offer a different approach to treating Depression.

Summary

Fortunately, there are many different treatments for TRD. Depression can be very difficult to live with – this holds true especially in cases where the condition fails to improve.

But there are many different strategies for improvement, which can hopefully lead to improvement.

See Also

• Depression Section
• What is the Prognosis for Depression?
• Therapy Homepage
• Medicine Homepage