How to manage severe depression that has resisted treatment?

Question

Hello doctor,

I am 54 and have been fighting major depression for almost 15 years now. I have tried Sertraline, Escitalopram, Venlafaxine, and now Bupropion, plus therapy, but nothing seems to help for long. Everything seems to work for the initial days, then stops. How does a 54-year-old manage severe MDD that has resisted 15 years of treatment?

Some weeks, I barely get out of bed. My doctor mentioned Ketamine, but I do not know if it really helps. I am exhausted from trying one after another. Does treatment-resistant depression ever actually get better?

I honestly do not remember what it feels like to enjoy life anymore.

Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I have gone through your query and understand your concern.

I can understand that it is difficult to live with long-standing and treatment-resistant depression (when major depression remains unchanged even after treatment with at least two different types of antidepressants).

Treatment-resistant depression (TRD) has specific management protocols that are different from those for usual depression, and yes, it does respond to treatment.

I believe four options are optimal for you. It all depends on which one you choose.

Yes, one option is Ketamine. It can provide relief within hours to days. It has some side effects, such as dissociation, and laryngeal spasms may occur. Usually, it is a safe, effective, and affordable option. You can undergo treatment two to three times a week. Each session takes almost 40 minutes.

Other options include augmentation with Lithium, antipsychotics, and ECT (electroconvulsive therapy, a form of mental health treatment involving sending an electric current briefly into the brain to cause a controlled seizure).

All these options are effective and can be considered. You have to choose depending on the side effects.

If you ask me, I would rather review the diagnosis, as sometimes bipolar disorder (an illness that is lifelong and involves serious changes in mood, energy, and activity levels) is present and is misdiagnosed as major depressive disorder.

Secondly, I would treat the contributing factors, such as

Vitamin B12 deficiency.
Vitamin D deficiency.
Substance abuse.
Constant psychosocial stress, or any other coexisting physical or psychiatric illness.

If I had to choose between these options, I would first suggest augmentation with Aripiprazole, as I have observed good effects with it. It may cause akathisia (a movement disorder) or insomnia (a sleep disorder) at the start, but you will usually adjust to it.

I hope I have answered your question.

Let me know if I can assist you further.

Thank you.