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Symptoms Still Lingering? It Could Be Treatment-Resistant Depression: TRD often requires a combination of treatments to overcome. Patience helps, too.

If you have been prescribed antidepressants, but you're not experiencing a change in mood or a softening of symptoms, you may have a common condition known as treatment-resistant depression (TRD). The definition of TRD varies, depending on who's defining it, but it applies to people whose symptoms have failed to improve after a certain number of antidepressant medication trials, explains David Mischoulon, MD, PhD, director of the Depression Clinical and Research Program at Massachusetts General Hospital.

"In some cases, the definition is based on number of antidepressant trials failed in the patient's lifetime, and in other cases it is based only on treatment failures in the current depressive episode," he adds. "Often not all symptoms will resolve completely with treatment, which is the typical scenario of TRD. The underlying causes for treatment resistance are unclear but likely multifold."

What Interferes with Treatment?

For many people, the causes of TRD are beyond their control. Having a complicated medical illness unrelated to depression can make treatment difficult. Other psychiatric disorders, such as drug or alcohol abuse, may also contribute to treatment resistance, Dr. Mischoulon says. Eating and sleep disorders may also make antidepressants less effective.

"Likewise, situational factors, such as financial or family stress, may also contribute to limited improvement," he adds. "Nonadherence to medication regimens is a common problem, particularly if the patient experiences side effects, and this too can delay or impede improvement."

As with antihypertensive medications or other powerful prescription drugs, antidepressants should be taken exactly as recommended by your doctor. You shouldn't suddenly stop taking a medication without consulting your doctor first.

And while research has uncovered considerable information about the causes and treatments of depression, there is still much to learn. One possible explanation for a person's TRD is that the root of his or her disorder may not be well understood and that antidepressant medication may not be the most effective treatment.

Getting Help

If you suspect that you or a loved one has TRD, the next step should be an assessment by a psychiatrist with expertise in TRD. "You want someone who is up on the latest treatments and who may offer creative approaches to finding the optimal treatment or combination therapy as needed," Dr. Mischoulon says.

A psychiatrist should take a close look at your health history and review all of your treatment efforts, including medications and other forms of therapy, such as cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT).

Dr. Mischoulon says the first step in trying to overcome TRD is to try different medications. "We may add psychotherapies such as CBT or DBT," he says. "If many medications have failed to provide benefit, we start to consider somatic therapies, particularly electroconvulsive therapy, or ECT, which is more effective but also carries a higher risk of cognitive side effects. ECT is considered one of the last-resort treatments for people who have failed to respond to many different antidepressants."

Nontraditional therapies, such as acupuncture, herbal supplements and meditation, may help some individuals. "They are probably best used as adjuncts to standard therapies since they often work best on people with milder forms of illness, and may not be so effective as monotherapies," Dr. Mischoulon explains.

Be Patient

TRD can be a frustrating complication for anyone already struggling with the challenges of depression. But it's important to understand that even with the most effective antidepressant medications, your brain needs time for the medications to start easing symptoms. Psychotherapy or any form of counseling also takes time to produce noticeable results.

Some cases of TRD are actually the results of patients simply giving up too early on their medications and counseling. An antidepressant should ideally be taken for at least six to eight weeks and at least two to four weeks at a dose higher than a "starting" dose. This is considered an adequate antidepressant trial.

"Antidepressant treatments, including medications and psychotherapy, can take several weeks to work optimally," Dr. Mischoulon says. "When embarking on a trial of any treatment for depression, the patient needs to understand that results may be a ways off and they must not give up on their treatment prematurely. Sometimes combinations of different medications and/or psychotherapy are needed to optimize results. The key is to not lose hope, and to work constructively with your doctor to find the right treatment."
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Publication:Mind, Mood & Memory
Date:Jan 30, 2020
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