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Treatment-resistant depression: What are your options when medication isn’t enough?

Depression is a very serious, life-threatening illness that, in today’s world, is still going widely unrecognized. An astounding 50 per cent or more of all depressive episodes go undiagnosed by physicians. Unfortunately, even when a medication is started, only 28 per cent of people respond to any given antidepressant.

This means most people who suffer from depression have to try two to three different medications before finding one that works. Treatment-resistant depression is often diagnosed once a person has failed to improve after taking two to three different antidepressants. If this sounds like you or someone you know, then keep reading to determine what the next step should be.

Re-evaluating medication

Sometimes this means more medication switches, but it’s a necessary evil. However, if there has been a small improvement, it may mean adding a second medication to give the first a “boost.” There are multiple medication combinations that can be attempted while waiting for other modalities of care. If you have yet to see a psychiatrist, then it might be something to consider now, as they are the experts in psychiatric medication combinations.


By the time someone has been diagnosed with severe or treatment-resistant depression, they have usually started therapy. However, many people don’t know that there are several types of psychotherapy. Cognitive behavioural therapy (CBT) has the best evidence to support its use in treatment-resistant depression. In short, CBT looks at the relationship between thoughts, feelings and behaviours, and attempts to unravel negative patterns. Other types of psychoptherapy, including interpersonal, psychodynamic, supportive and family psychyotherapy, may be also used if they have not yet been administered.


Although bibliotherapy is often only used in mild to moderate depression, it can be used in addition to other treatment modalities in severe or treatment-resistant depression. Bibliotherapy is, as the name implies, therapy through books. Self-help books that may be of use include Mind Over Mood: Change How You Feel by Changing the Way You Think by D. Greenberger and C. Padesky; Control Your Depression by P.M. Lewinsohn, R.F Munoz, M.A. Youngren and A.M. Zeiss; and Change Your Thinking: Overcome Stress, Anxiety, and Depression, and Improve Your Life with CBT by S. Edelman. Keep in mind that severe depression with suicidality should not be solely treated through bibliotherapy.

Transcranial magnetic stimulation (TMS)

TMS is a noninvasive option for treatment-resistant depression. An electromagnetic foil is placed on the patient’s scalp, and magnetic pulses are sent through the foil. TMS usually involves 10 to 30 treatment sessions of 15 to 45 minutes in length, administered once daily, five days a week. TMS might produce a transient headache or local pain but is generally very well tolerated and has no effect on memory. It is effective in 1 in 7 patients requiring the treatment, which is actually quite good considering all patients in this group did not get better with any previous treatments.

Electroconvulsive therapy (ECT)

ECT involves the administration of an electrical current to the brain via the scalp. This therapy does induce a seizure, and therefore general anesthesia is required for treatment. Memory loss, muscle pain and headaches can occur after administration of the treatment. However, ECT is more effective than TMS and often reduces the patient’s depressive symptoms by as much as 50 per cent.

Deep brain stimulation

This option is reserved for patients who have failed at least four other modalities of treatment. It requires neurosurgically implanting electrodes into the patient’s brain, which release stimulation throughout the patient’s life. In the past it has been used for Parkinson’s disease and is only more recently being used in depression.

Remember to rely on others when you have no strength left. Depression is as real as diabetes or heart disease, and the silent suffering needs to stop now. Never lose hope.

More on depression

Depression fallout: The impact of depression on couples
Helping a friend with depression
Pain and depression: What you should know

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