Depression Treatment Options

WHY ARE SOME DEPRESSIONS NOT RESPONSIVE TO CERTAIN TREATMENTS?

The diagnosis may not be correct.
The depression is a result of medications or medical conditions that need to be addressed.
Other medications interact with antidepressant drugs, making them less effective.
Ongoing drug or alcohol abuse can make it much more difficult to respond to any therapy.
The medication dose is inadequate or the medication is not taken for a long enough period of time (usually a minimum of 8 weeks) to see a therapeutic effect.
Individual differences in responsiveness. Probably due to different genetic vulnerabilities, some depressions are more responsive than others to specific treatments.

However, many people are correctly diagnosed with clinical depression, participate in psychotherapy, take antidepressant medications at a proper dose for a sufficient period of time, and still feel little to no relief. Such cases are considered “treatment-resistant depression.” If you suffer from treatment-resistant depression, it is important to be aware of all the treatment alternatives available to you so you can make the best decision for yourself.

TREATMENT OPTIONS FOR DEPRESSION

Fortunately, there are many different treatment options available to those suffering from depression. Each therapeutic alternative possesses specific risks and benefits. Below are some of the more common depression treatments utilized:

Psychotherapy (group, individual, or couples): Talk therapy is an excellent treatment for mild to moderate depression. Over time, therapy provides skills to adjust specific patterns of thought and/or behaviors that perpetuate depressive symptoms. While psychotherapy is non-invasive and drug-free, it does take time to work and may not be the best option on its own if depression is more severe or if there is an immediate risk of self-harm. Some specific styles of psychotherapy include:

Cognitive behavioral therapy (CBT)
Interpersonal
Mindfulness
Psychodynamic psychotherapy
Supportive psychotherapy

Psychotherapy and TMS are not mutually exclusive and, when done together, are likely to increase the chances of success. While TMS can help you get better and out of your clinically depressed state, psychotherapy can help you get well by encouraging you to make realistic but necessary changes in your life that complement the antidepressant effects of TMS. We highly encourage the continuation or initiation of psychotherapy while TMS is in progress.

Antidepressant medications:While the exact mechanisms of action of antidepressant medications are not completely clear, it is believed that they treat depression by altering the levels of neurotransmitters, such as serotonin, dopamine, and norepinephrine in the brain. For many patients, antidepressant medications quite effectively elevate mood and are often well-tolerated. However, others achieve inadequate relief or experience intolerable side effects or complications from drug therapy. Medications that alleviate depression for a period of time, can sometimes stop working.Medications and TMS: While many patients benefit from TMS without medication, others may have conditions that require simultaneous administration of medication and TMS. If a patient responds partially to a well-tolerated medication — depending on his or her prior psychiatric history and the severity of the presenting condition — our risk-benefit analysis may conclude that it is safer to stay on medication during TMS therapy rather than risk losing the gains already made from antidepressant treatment. So, as with TMS and psychotherapy, TMS and antidepressant medications are not necessarily mutually exclusive.

Augmentation agents: Augmentation treatments include thyroid hormones, mood stabilizers/anticonvulsants and antipsychotic medications. These strategies are often suggested when antidepressant therapy is not effective. While augmentation therapies work for many patients, these sometimes cause adverse side effects. Deciding whether or not to take patients off augmentation agents before or after TMS therapy depends on a number of factors, and involves a careful risk-benefit analysis specific for each patient.

Transcranial Magnetic Stimulation (TMS): TMS has been shown to be as effective as medication, without the burden of antidepressant-induced side effects. TMS works differently from medication and ECT as only magnetic pulses are utilized on a very specific area of the brain. Depending on how fast or slow the TMS pulses are applied, TMS can either stimulate or inhibit brain cell activity. While we do not yet know the exact mechanism of action of TMS, TMS may induce its antidepressant effects by alterations in brain regions directly involved in mood dysregulation. TMS is an easily tolerated, non-invasive treatment for depression with little risk of unwanted side effects.

Vagal Nerve Stimulation (VNS): This treatment is also an option that may be effective for medication-resistant depression. This option is invasive, as the VNS device is surgically implanted into the patient’s chest and a wire is run underneath the skin to connect to the left vagus nerve. This device produces electric pulses in order to stimulate the nerve to create signals that affect the mood center in the brain. Potential VNS complications include voice alteration and possible nerve paralysis. Since VNS is implanted by surgery, there are some surgical risks involved. TMS may not be an option for people who have VNS devices because of the potential for electro-magnetic interactions.

Electroconvulsive Therapy (ECT): ECT is a very effective treatment for depression, as patients are approximately 80% responsive. ECT is invasive as it deliberately causes a seizure and generally is performed in a hospital setting while the patient is sedated and under general anesthesia. In addition to the risks that anesthesia presents, ECT can cause memory difficulties, which sometimes can be sustained. Some people who have not responded to ECT have been shown to respond to TMS and vice versa.

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