The Importance of Exploring Options and Support for Treatment-Resistant Depression

Finding effective treatment for your depression is not always easy. It’s important to understand your options and know you aren’t alone.

I’ve lived with depression for many years, but it hasn’t always been treatment-resistant. Eight months ago, I was on an antidepressant combination that seemed to be working OK… until it stopped.

Before that, I’d been treatment-resistant for a few years — starting, stopping, and combining medications until my head was spinning (or was that another side effect?). I tried on and off-label medications and transcranial magnetic stimulation (TMS). I even collected meditation practices like I used to collect bouncy balls as a kid.

As my trial-and-error list continues to grow, I want more people to understand what treatment-resistant depression (TRD) is like, the options available, and how they can keep moving forward despite it all.

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What is treatment resistance anyway?

If you’re not familiar with the term, treatment resistance is a description of depression, not a diagnosis.

Anyone who’s finding it difficult to manage their treatment with several antidepressants may be considered treatment-resistant, but experts define it differently.

In 2017, when I signed up to try repetitive TMS, my insurance company defined TRD as having taken and not responded to at least two antidepressant medications at an optimal therapeutic dose. This seems to be the typical definition.

But in a recent application for ketamine treatment, the number of medications I had to have tried was 4, in at least two classes.

So your doctor, your insurance company, and a number of other organizations may define it differently. But if you’ve tried several first-line treatments without finding relief, you may be living with treatment resistance. Up to 30 percent of people with major depressive disorder (MDD) may have TRD.

Understanding your options when it feels like you’re running out of them

Living with treatment resistance means the list of things you’ve tried is getting long — I know mine is. But there are a lot of options and combinations that might just work for you.

No matter if you’re on treatment number 3 or 20, it can help to track what you’ve done, what worked, and what didn’t. This will be helpful if you switch doctors or sign up for treatments specifically for TRD. It will also help when you’re figuring out what to do next. Treatment for depression can take many forms and it’s important to know what’s out there.

Possible medications

Some of the various medication options for depression include:

• selective serotonin reuptake inhibitors (SSRIs)
• selective-norepinephrine reuptake inhibitors (SNRIs)
• tricyclic antidepressants (TCAs)
• monoamine oxidase inhibitors (MAOIs)
• noradrenergic and specific serotonergic antidepressants (NaSSAs)
• atypical antidepressants, like Wellbutrin and Trintellix
• mood stabilizers
• antipsychotics
• thyroid hormones (T3)
• esketamine (Spravato)

Psychotherapy

Various therapy techniques that have shown effectiveness for depression include:

• cognitive-behavioral therapy (CBT)
• interpersonal therapy
• behavioral activation therapy
• acceptance and commitment therapy (ACT)
• problem-solving therapy
• family or couples therapy

I don’t often go looking for a therapist who uses a specific type of psychotherapy (most of them practice CBT or some combination of therapies anyway), but some people find that something specific helps.

Really, the most important thing is to find a therapist that’s right for you.

Brain stimulation

Different types of brain stimulation therapy have also shown to help relieve depression. These include:

• repetitive transcranial magnetic stimulation (rTMS)
• electroconvulsive therapy
• vagus nerve stimulation
• deep brain stimulation

And more…

There are many other things people can do for depression — some may work, and others may not. These methods include:

• joining a support group
• taking certain supplements
• changing your diet
• moving your body more

The list of depression treatments is also growing, with ongoing clinical trials investigating alternative treatments for treatment-resistant depression, like psychedelics.

If you want to learn more about clinical trials in your area, you can visit the U.S. National Library of Medicine’s database of clinical trials.

Changing your perspective on recovery

It often feels isolating, but so many people are living with depression — 21 million U.S. adults in 2020 had an episode of MDD, and 280 million people are living with it worldwide.

Depression (and most mental health conditions) are complex. Some people have short episodes of mental health conditions and then move forward after treatment. Others, however, have to work each day to prevent relapse, manage symptoms, and just live in general.

If you’re on the treatment-resistant boat with me, you relate to the latter. But there are many people who try a medication, find symptom relief, and go on with their lives without depression.

I am happy for those people, but I don’t agree when they say they’ve been “cured.”

Using the word “cure” can make those of us living with chronic mental health conditions feel incurable. Personally, it makes me feel like those people have been “fixed,” and I’m just here, broken.

Instead, I focus on words like “recovery,” because that looks different for everyone.

Some people may recover and go back to their “normal” levels of functioning. For people living with TRD or other conditions (like bipolar disorder and persistent depressive disorder), recovery is more about management.

It’s not about fixing something broken, because we are not broken. And it isn’t about being symptom-free.

For me, it’s about functioning enough and managing the symptoms to do so. And that helps me in moments when I’m feeling hopeless or my depression is trying to tell me I’m broken.

Hope despite the darkness

Depression is characterized by hopelessness, and when you’re treatment-resistant, it can be particularly apparent. How do you feel hopeful when medication after medication fails to give you relief?

Some people will tell you to “have hope,” as if it’s as easy as flipping a switch. (These are often the same people who tell you to “just be happy,” which helps no one.)

To me, hope is like an argument I hope to win but know I won’t always. I work hard to find hope in the smallest of ways so I’m less likely to be crushed by disappointment. I go into new treatment options with realism and data, understanding that it may work for me, but it may not.

It’s taken time to get here though — as well as a support system made of friends, family, and healthcare professionals who are here for me in the ways that I need them.

My partner knows what a crisis looks like, and knows what to do when one comes up. My therapist works with me every month to get the tools I need to get by, survive, or thrive (depending on my functioning at the moment). My psychiatrist keeps listening and looking for treatments that might work for me.

The takeaway

It took a lot of steps to find and build my support system to get where I am today. Yes, I am treatment-resistant. Yes, my medication list is long and wieldy. But I am here. I am not alone — and neither are you.

I have support, data, and a new trial that may or may not work. But even if it doesn’t, I tried. And when you’re living with depression, fatigue, hopelessness, despair… isn’t trying truly something?

If you understand your options, prepare your support systems, and keep trying (despite your depression telling you to stop), I believe relief and remission are possible. I felt it before, after all.