Rehab for Treatment-Resistant Depression (TRD)

Treatment-resistant depression (TRD) has the same symptoms as depression, but with a more complex and challenging recovery process. And those very symptoms can make it difficult to seek help.

Although the journey to recovery from treatment-resistant depression can feel daunting, there are a growing number of treatment options available. And the more you know about your diagnosis, the more easily you can manage your symptoms and get the care you need.

Defining Treatment-Resistant Depression
Although it’s similar to major depressive disorder in many ways, treatment-resistant depression has its own set of clinical characteristics.¹ Specifically, TRD is defined as depression with symptoms that are not alleviated after trying 2 or more treatment options (medications) for at least 6 weeks each. Despite the myriad medical and behavioral options for treating depression, many people still struggle to find an effective treatment. ⅓ of people with major depression have TRD.²

If you think you may have this diagnosis, you’re likely already familiar with the symptoms of major depression.³ As stated by the American Psychiatric Association, the condition’s classic signs are as follows:

• feeling sad or having a depressed mood
• loss of interest or pleasure in activities once enjoyed
• changes in appetite — weight loss or gain unrelated to dieting
• trouble sleeping or sleeping too much
• loss of energy or increased fatigue
• increase in purposeless physical activity (e.g., inability to sit still, pacing, handwringing) or slowed movements or speech (these actions must be severe enough to be observable by others)
• feeling worthless or guilty
• difficulty thinking, concentrating or making decisions
  thoughts of death or suicide

If you’re thinking about suicide, get help right away. You can call the National Suicide Prevention Lifeline at 1-800-273-8255 to talk to someone, 24/7.

While these criteria are well understood, researchers are still exploring their underlying causes. Most people understand depression to be related to chemical factors in the brain. And research has confirmed that, even more than major depression, treatment-resistant depression has a genetic basis.¹

Genetics aren’t the only cause of this illness. There are also a number of environmental factors that may contribute to depression⁴ —and it’s not just physical health. It has been associated with more frequent use of screens (cell phones, computers, etc.), and a lack of access to green space. High levels of air and noise pollution can also exacerbate symptoms. On the other hand, activities that guard against depression include confiding in other people, being part of a sports club or gym, and getting adequate sleep.

But there’s no quick fix for mental health. Even if you sleep for 8 hours a night and go to the gym every day, you may still experience depressive symptoms. And TRD can make you vulnerable to other conditions, like substance use disorders.

TRD and Substance Use Disorders

According to a 2019 study, patients with treatment-resistant depression are at a higher risk for developing addictions⁵ than those with more easily treated major depressive disorder. And the reverse is also true: patients with substance use disorders may be more susceptible to developing TRD,⁶ even after they seek help.

These findings have serious implications for the recovery process. If you have a history of either one of these conditions, you may be at risk of developing the other. And if you’re showing symptoms of both, you might want to consider treatment for co-occurring disorders.

Residential rehabs that offer this type of treatment may take a more nuanced approach. For example, you might work closely with your providers to develop an individualized plan of care. Depending on your exact program, you may have more or less say in which types of therapy you engage in during your stay.

Types of Therapy for Treatment-Resistant Depression

By definition, it’s challenging to find treatment for TRD. But remission is still possible. A growing body of research suggests that some therapies may be highly effective for patients with this diagnosis.

Medications

To be diagnosed with TRD, you must have tried at least 2 types of medication with little to no effect. Depending on which prescriptions you’ve taken so far, it may be worth continuing to experiment. For example, you might start by taking an SSRI (like Prozac) and then switch to a non-SSRI (like Wellbutrin). Some studies show that the act of switching medications may improve the symptoms of TRD.⁷

Ketamine Therapy

Ketamine therapy is an increasingly popular treatment for depressive disorders. A growing body of research supports the idea that ketamine may be especially effective for patients with treatment-resistant depression.⁸ This medication is normally administered in a controlled environment, facilitated by a psychotherapist and a medical team. During each session, you’ll receive an infusion of ketamine and enter a trance state, in which you may be able to process and accept difficult emotions. You’ll have time to talk about your experience afterward, either in a group or 1 on 1 with your therapist.

Transcranial Magnetic Stimulation (TMS)

Transcranial magnetic stimulation (TMS) is a comparatively new therapy for treatment-resistant depression.⁹ During a TMS session, a series of magnetic pulses are used to stimulate the brain. According to the American Psychiatric Association, “the procedure, which is noninvasive and painless, is conducted in the outpatient setting. Unlike electroconvulsive therapy (ECT), patients need no anesthesia or sedation.”

Studies show that TMS causes noticeable improvement in patients with treatment-resistant depression.¹⁰ Preliminary data suggest that this modality may be especially effective when combined with other approaches, like ongoing medications and psychotherapy.

Psychotherapy

Talk therapy, or psychotherapy, is a broad category. It includes modalities like cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), interpersonal psychotherapy, and more. Talk therapy is helpful for most mental health conditions, including treatment-resistant depression. However, different patients may benefit more from some specific types of therapy than others. Work with your provider to assess which format will best meet your needs.

Chris Aiken, MD, explains that talk therapy has “a slightly larger effect than pharmacotherapy” for patients with treatment-resistant depression.¹¹ This modality offers patients ongoing support, and can dynamically respond to challenging situations in a way that medication just can’t. If you’re dealing with a sudden life change—like the loss of a job or relationship—you can easily schedule an extra session with your therapist. Changing or upping your medication is a much longer process.

Studies show that psychotherapy can amplify the effects of other TRD treatments,¹² such as pharmacotherapy (the use of prescription meds). And although more research is needed in this area, most rehab programs already invite patients to engage in more than one therapeutic modality.