From medications to ECT to therapy to TMS to ketamine, you haven't tried it all.
If you have depression and feel like you’re not getting better, the most important thing is to make sure you’ve given your first treatment a fair shake. This means communicating with your doctor to make sure you’ve tried the medication at the right dose for the right amount of time (usually at least 4 or 6 weeks). If you’ve tried your antidepressant medication at a high enough dose for long enough and still aren’t feeling better, then you may have treatment-resistant depression (TRD).
There are several approaches that your doctor might take for TRD. Typically, the first approach is to either augment (or strengthen) your treatment by adding another medication type. This is typically an antipsychotic medication, lithium, thyroid hormone, or another antidepressant from another class. Another option is to switch to another treatment. In this case, typically a patient will be switched to another antidepressant, switched to psychotherapy (“talk” therapy), or switched to transcranial magnetic stimulation (TMS). Finally, it is possible that your doctor will decide to keep your current medication and add on psychotherapy or TMS.
Often, availability of these treatments is a major factor being considered for your treatment. For instance, many communities have a scarcity of psychotherapists or TMS providers, so your doctor may opt for augmenting your treatment with another medication or changing your antidepressant before referring for these services.
If you have severe depression that is resistant to treatment with antidepressants, electroconvulsive therapy (ECT) is often the treatment of choice. ECT is often selected for people who have ongoing suicidal thoughts with intent, severe weight loss, malnutrition, or dehydration, for those who have additional psychotic symptoms, or for those who have catatonia (a state of abnormal movements, immobility, withdrawal, stupor, etc.). ECT is often considered the most effective treatment for depression and is frequently used for patients who are not able to improve with medications alone.
For severe treatment-resistant depression, ketamine and esketamine are additional considerations. These are very similar, with esketamine being a close chemical relative to ketamine that is more easily delivered as a nasal spray (ketamine is usually given intravenously). These haven’t yet been compared head-to-head in a clinical trial, so typically a patient's access to these is based on local availability. Ketamine/esketamine can be very fast-acting options for patients with TRD, but they cannot be given to patients that have a history of psychosis and their safety and effectiveness is not as established as other treatments, given that they’re generally a newer treatment for depression.
Psychedelics, specifically psilocybin, is still under investigation but has been granted a Breakthrough Therapy designation by the FDA for treatment-resistant depression. Psilocybin and another common psychedelic, MDMA, are still Schedule 1 substances in the USA, meaning they are illegal for use outside of clinical trials. The complete legal framework varies by substance and by state and country. Some therapists have made themselves available for integration therapy, where they help incorporate insights, challenging lessons, and new perspectives into the full totality of your everyday existence. These therapists do not give substances or sit with people who have taken substances during integration sessions, and they do not condone or recommend use of illegal substances.
Whether you’ve tried one antidepressant or one hundred, you have options. Patients who are persistent in their depression treatment and who partner with their doctor can overcome their depression. Your options are nearly infinite, and you never know which combination will be the one that works for you. Keep your head up, and stick with it!
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