Treatment-resistant depression (TRD) typically refers to an inadequate response to at least one antidepressant trial of adequate dose and duration among patients experiencing major depressive disorder (MDD). Or is it two antidepressant trials? And while we’re at it, what’s an adequate dose and duration of use? It varies, depending upon whom you ask and where you research. And then there are the issues of how compliant the patient is (or was) with the medication and to what extent their biases have affected outcomes.
Such is the longstanding, nebulous and so often poorly-defined world of Psychiatry, with its propensity for providing inadequate standardizations of clinical terminology that continuously have us scratching our heads.
Notice in the TRD definition above that there is a singular determinant as to whether a depressed individual fits in this category – response to antidepressants. Should antidepressant response be the SOLE judge? I think not, because current antidepressants are NOT disease modifying. But this isn’t stopping clinical trials and observational studies which are investigating the role that psychedelics such as LSD and psilocybin (magic mushroom) may play in depression management. After all, we’ve already got a ketamine clone (Spravato), which is FDA-approved for depression. The search for the magic bullet(s) continues.
Treatment-Resistant depression is not untreatable – despite the paltry track record of current antidepressants. The challenge is to help patients distance themselves from the toxic trap of disconnection which drives depression. I’ll often say to patients, “you deserve a full recovery and I am committed to helping you achieve that, but we’ll need more than just reliance on medications to get you there.” I don’t want them passively waiting for the next ballyhooed medical miracle which promises to change their brain chemistry. Of course, I’ll discuss the benefits of intensive, cognitive-behavioral therapy and its offspring therapy models as well as “mechanical” interventions such as Transcranial Magnetic Stimulation (TMS), Deep Brain Stimulation (DBS) and ECT. But before going in these directions, I’ll suggest we begin with some lifestyle changes which can enhance both the clinical and biological effects of antidepressants. The following are lifestyle modifications I recommend to TRD patients of mine:
Fix the Physiology
Scientific evidence is clear and resources are abundant that regular exercise and nature significantly reduce depression, because both return us to our more natural and healthy animal state – where we are moving and our endorphins are rushing. Start the day with a walk around the block, just one block at first. This is a simple way to get the blood flowing and create energy.
Once a Week, Pack up One Small Box for Donation
There are few, if any initiatives that instill feelings of gratitude more so than donating something for the betterment of others. It reminds us that in spite of our current plight, there are others in even more dire straits.
A Daily Account of: “3 Things That Brought Me Joy Today”
Keep these brief and describe them in no more than one sentence. The focus should exclusively stay on what was rewarding, satisfying and pleasant about each day.
Mental Health Apps
Skepticism abounds when it comes to smartphone “therapy,” but there is an ever-increasing body of evidence indicating that some apps can make a difference in the absence of professional counseling. Among apps with a CBT focus, the following have some research support: Moodivate, Happify, Stress Free, Virtual Hope Box, and Intellicare.
To avoid overwhelm, I encourage TRD patients to choose only one of the above. And I’ll encourage them to focus on being “chronically creative” by devising their own lifestyle modifications – as opposed to dwelling on being “chronically depressed.”
My core message to those believing that they’re mired in treatment-resistant depression is that they can live a full, productive life in spite of the chronicity of their symptoms.
It’s work for sure, but opportunities for connection are numerous… and often free.
Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.