What is Treatment Resistant Depression? What Do We Do about it?

Treatment resistant depression is defined as having 2 failed, 6-week antidepressant trials. Another way of putting is, you have depression, you take medication for at least 6 weeks and you don’t get better. Then you try another medication and still no luck.

However, when you take the medication, you need to take it at a minimally therapeutic dose for 6 weeks. This is usually not the starting dose. For example, the minimally therapeutic dose of Zoloft for depression is 50mg – 100mg. The maximum dosage is 200mg. If you see a doctor and are put on 25mg and stay there for 2 months and don’t feel better, that’s not a failed trial of the medication. The first step is to increase the dose to a minimum of 50mg but likely 100mg before making a final decision. In my own practice, I wouldn’t consider 6 weeks on 50mg a failure. However, sometimes you are unable to increase the dose without getting a lot of side effects. So, you may have noticed a tiny improvement with 50mg, your doctor increases you to 100mg and you lose your sex drive, or you get insomnia.

If this is the case, you haven’t failed Zoloft, you’re limited by side effects. Your doctor would probably still switch you to another medication because you need to be able to tolerate the medication enough to get it up to a therapeutic dose. I mention this because side effects are common and if you’ve tried 3 or 4 antidepressants and had to stop because of side effects, this doesn’t mean you’re treatment resistant.

Medication options for treatment resistance:
The atypical antipsychotics: Abilify, Seroquel, Zyprexa and Rexulti.
Lithium
Thyroid hormone
Mirtazepine
Mirapex (pramipexole)
L-Methylfolate
SamE

Non-medication options are:
Electroconvulsive therapy (ECT)
Transcranial Magnetic Stimulation (TMS)

For more information on Depression, see the Depression playlist https://goo.gl/eFCdQo

References
The thing about 40-60% of TRD being bipolar
Francesca, MM et. Al. Clin Pract Epidemiol Ment Health, 2014; 10:42-47

Lithium reducing suicide risk
Tondo L et al, Curr Psychiatry Rep 2016;18:88

Cohen BM, Sommer BR, Vuckovic A. Antidepressant-Resistant Depression in Patients With Comorbid Subclinical Hypothyroidism or High-Normal TSH Levels. Am J Psychiatry. 2018;175:598-604

Disclaimer: All of the information on this channel is for educational purposes and not intended to be specific/personal medical advice from me to you. Watching the videos or getting answers to comments/question, does not establish a doctor-patient relationship. If you have your own doctor, perhaps these videos can help prepare you for your discussion with your doctor.

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