If you've been treated for depression but your symptoms haven't improved, you may have treatment-resistant depression. Taking an antidepressant or going to psychological counseling (psychotherapy) eases depression symptoms for most people. But with treatment-resistant depression, standard treatments aren't enough. They may not help much at all, or your symptoms may improve only to keep coming back. Treatment-resistant depression symptoms can range from mild to severe and may require trying a number of approaches to identify what helps.
Your family doctor can prescribe antidepressants and give you advice. But if your depression symptoms continue despite treatment, see a medical doctor who specializes in diagnosing and treating mental health conditions (psychiatrist). You may also need to see a psychologist or other mental health professional for psychological counseling.
If your depression treatment isn't working, your doctor will consider your situation. He or she will review your medical history, and may:
- Ask about any life situations that might be contributing to your depression.
- Consider your response to medications, psychotherapy or other treatments you've tried.
- Review all of the medications you're taking, including nonprescription drugs and herbal supplements.
- Make sure that you're taking your medications as prescribed and following other treatment steps.
- Consider a diagnosis of bipolar disorder or another mental health condition that can cause or worsen depression. Other mental health conditions may require a different treatment approach.
- Consider your physical health. Physical health conditions can sometimes cause or worsen depression. Examples include thyroid disorders, chronic pain, anemia and heart problems.
Here are some things you and your doctor may look into when standard depression treatments aren't effective.
Even if you've already tried an antidepressant and it didn't work, don't lose hope. You simply may not have found the right dose, medication or combination of medications that works for you. Here are some medication approaches you and your doctor may consider:
- Giving your current medications more time. Antidepressants and other medications for depression typically take four to eight weeks to become fully effective and for side effects to ease up. For some people, it takes even longer.
- Increasing your dose. Because people respond to medications differently, you may benefit from a higher dose of medication than is usually prescribed. Discuss with your doctor whether this is an option for you. Don't alter your dose on your own.
- Switching antidepressants. For a number of people, the first antidepressant tried isn't effective. You may need to try several before you find one that works for you. Your doctor may have you switch from one antidepressant to another in the same class. Or you may try a different type of antidepressant altogether.
- Adding another type of antidepressant. Your doctor may prescribe two different classes of antidepressants at the same time. That way they'll affect a wider range of brain chemicals linked to mood (neurotransmitters that include dopamine, serotonin and norepinephrine).
- Adding a medication generally used for another condition. Your doctor may prescribe a medication that is generally used for another mental or physical health disorder, along with an antidepressant. This approach is known as augmentation. There are numerous medications that may be tried, including anti-anxiety medications, anti-seizure medications, mood stabilizers, beta blockers, antipsychotics and stimulants.
- Using the cytochrome P450 (CYP450) genotyping test. This test checks for specific genes that indicate how well your body can process (metabolize) a medication. It isn't a sure way to tell which antidepressant will work, but for some people this test can indicate whether a particular antidepressant might be a good choice based on how likely it is to cause side effects. Your local hospital may not provide genetic tests, but laboratory testing may be available through national laboratories.
Psychological counseling (psychotherapy) can be very effective. For many people, psychotherapy combined with medication works best. It can help identify underlying concerns that may be adding to your depression. For example, psychotherapy can help you find better ways to cope with life's challenges, address past emotional trauma and manage relationships in a more healthy way.
If counseling doesn't seem helpful, talk to your psychotherapist about trying a different approach. Or consider seeing someone else. As with medications, it may take several tries to find a treatment that works. Psychotherapy for depression can include:
- Cognitive behavioral therapy. This common type of counseling addresses thoughts, feelings and behaviors that affect your mood. It helps you identify and change distorted or negative thinking patterns and teaches you skills to respond to life's challenges in a positive way.
- Interpersonal psychotherapy. Interpersonal psychotherapy focuses on resolving relationship issues that may contribute to your depression.
- Family or marital therapy. This type of therapy involves family members or your spouse in counseling. Working out stress in your relationships can help with depression.
- Group psychotherapy. This type of counseling involves a group of people who struggle with depression working together with a psychotherapist.
- Psychodynamic treatment. The aim of this counseling approach is to help you resolve underlying problems linked to your depression. This type of treatment can take longer than other types of psychotherapy because it involves exploring your feelings and beliefs in-depth.
Procedures to treat depression
If medications and psychotherapy aren't working, you may want to talk to a psychiatrist about these additional treatment options:
- Electroconvulsive therapy (ECT). In ECT, electrical currents are passed through the brain to trigger a brief seizure. Although many people are leery of ECT and its potential side effects (such as confusion or amnesia), it can offer immediate relief of even severe depression when other treatments don't work.
- Vagus nerve stimulation. This treatment uses a device implanted in your chest that's connected by a wire to a nerve in your neck (the vagus nerve). Electrical signals from the implant travel along the vagus nerve to the mood centers of the brain, which may improve depression symptoms.
- Transcranial magnetic stimulation. With this treatment, magnetic fields are used to alter brain activity. A large electromagnetic coil is held against your scalp near your forehead to produce an electrical current in your brain. As with ECT and vagus nerve stimulation, transcranial magnetic stimulation appears to improve depression by stimulating areas of your brain that control mood.
Other steps you can take
There are a number of things you can do to make the most of depression treatment:
- Take your medications exactly as prescribed. Treatment may not work if you stop taking your medication, skip or lower a dose, or forget to take a dose. Many people get off track. This can happen for a number of reasons, including problems with side effects, thinking you don't need a medication because you feel better or simply forgetting. If you do stop taking your medication, contact your doctor to address any problems and get back on track. If the cost of the medication is a problem, talk to your doctor about it — he or she may be able to suggest ways to reduce the cost of treatment.
- Stop drinking or using drugs. Many people with depression drink too much alcohol or use illegal drugs, which worsens depression. If you can't stop drinking alcohol or using drugs on your own, talk to your doctor or mental health provider. Depression treatment may be unsuccessful until you address your substance use.
- Manage stress. Relationship issues, financial problems, an unhappy work life and a number of other issues can all contribute to stress, which in turn worsens depression. Try stress-reduction techniques such as yoga, meditation or journaling. Psychotherapy can be especially helpful in resolving stressful situations and learning how to reduce the effects of stress in your life.
- Sleep well. Poor sleep may worsen your depression. Both the amount of time you sleep and how well you sleep can affect your mood, energy level, ability to concentrate and resilience to stress. If you have trouble sleeping, research ways to improve your sleep habits on your own or ask your doctor or mental health provider how to improve your sleep.
- Get regular exercise. Exercise has a direct effect on mood. Even gentle physical activity such as gardening or walking can reduce stress, improve sleep and ease depression symptoms.
Don't settle for a treatment that's partially effective at relieving your depression, or one that works but causes intolerable side effects. Keep working with your doctor and other mental health providers to find the best treatment possible, even though it may take time and effort to try new approaches.