Can TMS help if my antidepressant is not working?

Question

Hello doctor,

I am a 30-year-old male with major depressive disorder. I have been on Escitalopram for four months and still have low motivation, exhaustion, and concentration problems.

Should I switch to another antidepressant or try Bupropion?
Are there other drugs that work, like Ketamine and TMS?

Please guide.

Answer 1

Hello,

Welcome to icliniq.com.

I read your query, and I understand your concern.

You have been on Escitalopram for major depressive disorder for four months, and you have some residual symptoms like lack of motivation, fatigue, and poor concentration. This represents a partial response to treatment.

The first course of action would be switching to Bupropion (Wellbutrin), which has been known to help with energy, motivation, and concentration. This medication is unlikely to produce weight gain and sexual dysfunction like SSRIs (selective serotonin reuptake inhibitors). It may prove useful, especially if your chief complaints are fatigue, poor concentration, or blunted affect. But it has been known to increase anxiety in some people.

Another course of action may be to continue Escitalopram and augment it with another drug. Escitalopram with Bupropion can address energy and concentration problems without giving up the antidepressant effects of escitalopram. Another alternative in augmentation therapy includes low-dose atypical antipsychotics such as Aripiprazole or Quetiapine, which, although very useful, may cause side effects like weight gain, sedation, and metabolic effects. In cases where patients are resistant to treatment, lithium or T3 may be used.

In case the symptoms remain unchanged despite proper medication trials, new treatment methods could be considered. Treatment with Ketamine or Esketamine (Spravato) leads to rapid antidepressant results, usually in hours or days, and these methods are mostly used for patients with treatment-resistant depression.

Ketamine and Esketamine require multiple procedures under professional medical supervision, and their cost could be relatively high, but the long-term effects of these methods are being researched.

Another treatment method is transcranial magnetic stimulation (TMS). This is a non-invasive procedure of brain stimulation therapy that includes 20 to 30 procedures over several weeks. The TMS method proves to be efficient for numerous patients with treatment-resistant depression and does not cause serious side effects, only some headaches and discomfort on the head.

It is also crucial to talk to your psychiatrist about whether it would be better to try bupropion or add-on therapy in your case. Furthermore, other possible sources of fatigue and inability to concentrate should also be excluded. Such problems could be caused by thyroid problems, vitamin B12 deficiency, anemia, or sleep disorders. In case medication does not help after proper trials, advanced methods like TMS or Ketamine or Esketamine should be considered.

I hope this helps you.

Take care.