Treatment-Resistant Depression: Your Continuum of Care

If you've been diagnosed with treatment-resistant depression, you might be wondering what happens next. You've already tried some medications. Maybe you've already tried talk therapy, too. They haven't helped. So what now?

"Having treatment-resistant depression is a terrible burden for people," says Ian A. Cook, MD, director of the Depression Research Program at the University of California Los Angeles. "But they really should hold on to some optimism." Success might not come overnight. But with some patience and effort, you and your doctor can find an approach that will help.

Unfortunately, there's no simple step-by-step plan to tackle treatment-resistant depression. Every case is different. But this article will give you an idea of how your doctor and therapist might think about your treatment. There are three basic approaches for treatment-resistant depression: medications, psychotherapy, and brain stimulation treatments. Here's a guide to the options.

Medications for Treatment-Resistant Depression

If you have treatment-resistant depression, you've already tried some medications. Nonetheless, your doctor -- preferably an expert at treating the condition -- will likely recommend that you try again with a new approach.

You might be skeptical about going onto yet another medication. But keep in mind that there are lots of different drugs available and they work in different ways. Often it takes time -- and trial and error -- to find the right drug at the right dose or in the right combination, says Dean F. MacKinnon, MD, associate professor of psychiatry at the Johns Hopkins Hospital in Baltimore.

Here are your drug options for treatment-resistant depression:

Newer antidepressants. These include SSRIs -- like Prozac, Celexa, and Zoloft -- as well as drugs from other classes, like Effexor, Cymbalta, Wellbutrin, and Remeron. Generally, doctors are likely to start with these drugs.  

Another new antidepressant, Symbyax, combines the active ingredient in Prozac with an antipsychotic, the active ingredient in Zyprexa. This combination medicine is the first drug approved by the FDA to specifically treat acute treatment-resistant depression.

Older antidepressants. These include tricyclic antidepressants or TCAs (like Elavil and Pamelor) and Monoamine Oxidase Inhibitors or MAOIs (like Nardil and Parnate.) While these drugs can help with treatment-resistant depression, many doctors only turn to them when other antidepressants have failed. They tend to have more severe side effects. MAOIs can cause dangerous interactions with other drugs and foods.

Other medications. Antidepressants aren't the only type of drug for treatment-resistant depression.Sometimes using an antidepressant and then adding a medicine from a different class -- a technique called augmentation -- can help. Some of these drugs include lithium, antianxiety drugs, anticonvulsants, antipsychotics, and others. While not truly a drug, Deplin -- a prescription medicinal food that contains folate -- is also used to enhance the effect of an antidepressant.

Where will your doctor start?  It really depends on the person. Here are some of the things that your doctor will consider when deciding what drug treatment to try next.