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Treatment-resistant depression

Sometimes depression doesn't get better, even with treatment. Explore what you can do about it.

By Mayo Clinic staff

Managing Depression

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If you've been treated for depression but your symptoms haven't improved, you may have treatment-resistant depression. Taking an antidepressant or going to psychological counseling (psychotherapy) eases depression symptoms for most people. But with treatment-resistant depression, standard treatments aren't enough. They may not help much at all, or your symptoms may improve only to keep coming back. Treatment-resistant depression symptoms can range from mild to severe and may require trying a number of approaches to identify what helps.

Your family doctor can prescribe antidepressants and give you advice. But if your depression symptoms continue despite treatment, see a medical doctor who specializes in diagnosing and treating mental health conditions (psychiatrist). You may also need to see a psychologist or other mental health professional for psychological counseling.

If your depression treatment isn't working, your doctor will consider your situation. He or she will review your medical history, and may:

  • Ask about any life situations that might be contributing to your depression.
  • Consider your response to medications, psychotherapy or other treatments you've tried.
  • Review all of the medications you're taking, including nonprescription drugs and herbal supplements.
  • Make sure that you're taking your medications as prescribed and following other treatment steps.
  • Consider a diagnosis of bipolar disorder or another mental health condition that can cause or worsen depression. Other mental health conditions may require a different treatment approach.
  • Consider your physical health. Physical health conditions can sometimes cause or worsen depression. Examples include thyroid disorders, chronic pain, anemia and heart problems.

Here are some things you and your doctor may look into when standard depression treatments aren't effective.

Medication strategies

Even if you've already tried an antidepressant and it didn't work, don't lose hope. You simply may not have found the right dose, medication or combination of medications that works for you. Here are some medication approaches you and your doctor may consider:

  • Giving your current medications more time. Antidepressants and other medications for depression typically take four to eight weeks to become fully effective and for side effects to ease up. For some people, it takes even longer.
  • Increasing your dose. Because people respond to medications differently, you may benefit from a higher dose of medication than is usually prescribed. Discuss with your doctor whether this is an option for you. Don't alter your dose on your own.
  • Switching antidepressants. For a number of people, the first antidepressant tried isn't effective. You may need to try several before you find one that works for you. Your doctor may have you switch from one antidepressant to another in the same class. Or you may try a different type of antidepressant altogether.
  • Adding another type of antidepressant. Your doctor may prescribe two different classes of antidepressants at the same time. That way they'll affect a wider range of brain chemicals linked to mood (neurotransmitters that include dopamine, serotonin and norepinephrine).
  • Adding a medication generally used for another condition. Your doctor may prescribe a medication that is generally used for another mental or physical health disorder, along with an antidepressant. This approach is known as augmentation. There are numerous medications that may be tried, including anti-anxiety medications, anti-seizure medications, mood stabilizers, beta blockers, antipsychotics and stimulants.
  • Using the cytochrome P450 (CYP450) genotyping test. This test checks for specific genes that indicate how well your body can process (metabolize) a medication. It isn't a sure way to tell which antidepressant will work, but for some people this test can indicate whether a particular antidepressant might be a good choice based on how likely it is to cause side effects. Your local hospital may not provide genetic tests, but laboratory testing may be available through national laboratories.

Psychological counseling

Psychological counseling (psychotherapy) can be very effective. For many people, psychotherapy combined with medication works best. It can help identify underlying concerns that may be adding to your depression. For example, psychotherapy can help you find better ways to cope with life's challenges, address past emotional trauma and manage relationships in a more healthy way.

If counseling doesn't seem helpful, talk to your psychotherapist about trying a different approach. Or consider seeing someone else. As with medications, it may take several tries to find a treatment that works. Psychotherapy for depression can include:

  • Cognitive behavioral therapy. This common type of counseling addresses thoughts, feelings and behaviors that affect your mood. It helps you identify and change distorted or negative thinking patterns and teaches you skills to respond to life's challenges in a positive way.
  • Interpersonal psychotherapy. Interpersonal psychotherapy focuses on resolving relationship issues that may contribute to your depression.
  • Family or marital therapy. This type of therapy involves family members or your spouse in counseling. Working out stress in your relationships can help with depression.
  • Group psychotherapy. This type of counseling involves a group of people who struggle with depression working together with a psychotherapist.
  • Psychodynamic treatment. The aim of this counseling approach is to help you resolve underlying problems linked to your depression. This type of treatment can take longer than other types of psychotherapy because it involves exploring your feelings and beliefs in-depth.
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References
  1. Katon W, et al. Treatment of resistant depression in adults. http://www.uptodate.com/home/index.html. Accessed May 10, 2011.
  2. Preskhorn SH. Treatment options for the patient who does not respond well to initial antidepressant therapy. Journal of Psychiatric Practice. 2009;15:202.
  3. Shelton RC, et al. Therapeutic options for treatment-resistant depression. CNS Drugs. 2010;24:131.
DN00016 Aug. 23, 2011

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