Treatment-resistant depression (TRD)

TRD can initially be difficult to diagnose, it always requires a review of the entire treatment process for your depression so far. This may have been limited to prescription medication from your GP, where full analysis of type of medication and dosage used will be required, to see if there is an alternative drug which could prove more beneficial.

When you first meet with your specialist at Priory, you will be able to discuss the reasons why treatment hasn’t worked so far, and confirm that you haven’t been misdiagnosed.

Your specialist will reassess you and review the diagnosis. This may involve blood tests, and other medical investigations, which will confirm that we are not missing another physical or psychiatric disorder.

Inpatient treatment for TRD

While we can offer treatment for depression on an outpatient, inpatient and day care basis, when receiving treatment for TRD, you may receive more intensive residential based depression treatment at one of our hospitals. This involves a more structured treatment programme in an attempt to find a solution to your TRD, and can help remove any negative influences on your depression from your environment.

The time, care and attention available during your stay can greatly improve your quality of life, and helps both yourself and Priory staff work through the reasons why your initial treatment for depression may not have been successful, including any emotional or physical issues that may not have been addressed.

Evidence based therapies will be used that are suited to your individual circumstances, targeting the aspects of your depression that have not yet been resolved, providing the best possible chance of recovery.                                            

Diagnosis of TRD

There are other conditions such as bipolar depression which doesn’t respond as well to anti-depressants, hypothyroidism, alcohol and substance addiction which can have similar symptoms but require different treatment methods.

It is also important to determine whether you have other disorders such as an anxiety disorder or eating disorder which may be further complicating your treatment.

Medication for TRD

Making sure you have been regularly taking prescribed anti-depressants at the right dose and length of time to have a sufficient effect will be the next stage of treatment for TRD.

While you may find it frustrating when several medications to treat your depression don’t work as they should, our consultants will work with you to find the right medication or combination of medications for your individual circumstances.

If you have severe or long-term depression, it can take time to find medication that is effective. The challenge is to find a particular type of anti-depressant, which affects the part of brain which controls your mood, which works to effectively improve your symptoms where other drugs haven’t.

Switching from one type of anti-depressant to another which has different properties can help, while it is also possible to add a second anti-depressant or other medications that aren’t usually used for treating depression. This can be especially useful when you are feeling some relief from depression symptoms but the condition is not yet completely under control.

It may be that you were not able to take the prescribed medication because of adverse effects. A change of medication will allow us to treat you more effectively with medication that you are able to tolerate.

Therapy for TRD

A combination of medication and therapy treatment is often the most effective way to treat depression and TRD where medication alone has not proved to be effective. While medication can relieve many of the most problematic symptoms of depression, individual or group-based psychotherapy allows you to work with your specialist therapist to understand specific issues or concerns which may be contributing to the illness.

Therapy sessions at Priory for treating TRD can help you:

• Learn new coping mechanisms to copy with stressful life events
• Manage relationships more effectively
• Work through past trauma which may be stopping you from recovering sufficiently
• Discuss any patterns of substance abuse and understand how this may worsen or cause symptoms of depression
• Replace or adjust negative emotions or beliefs with more positive thinking

The evidence-based treatment therapies we most commonly use to treat depression and TRD at Priory include:

Cognitive behavioural therapy (CBT)

This form of therapy is used worldwide for treating a variety of mental health conditions. CBT allows you to address any issues with your therapist regarding the thoughts, feelings and behaviours you have which are linked to your mood when you have depression.

The aim of CBT sessions is to challenge any negative thinking or beliefs you may have that may be contributing to your depression, and encourage lifelong methods of dealing with challenges in a more positive mindset.

Effective CBT sessions can help ensure that you are equipped with sufficient coping mechanisms throughout your life, so that there is less chance that you will become depressed again.

Group therapy

While group therapy sessions can appear daunting at first, particularly when following a period of one-to-one sessions, they are often very therapeutic experiences where you are able to listen to and exchange personal stories of depression and the recovery process with other patients.

This format can offer mutual support and guidance in a compassionate setting when you are seeking a solution to TRD, and can be particularly effective when trying to overcome symptoms of depression.   

Family therapy

Because depression can impact the lives of those closest to you as well as yourself, family therapy works by involving family members and yourself in the therapeutic process. This can help establish new lines of communication and improve understanding of what is ultimately a complex condition, and allows you see how your illness is affecting others as well as yourself.

Family therapy can be hugely beneficial for families living with depression, where you are all able to contribute to supporting each other through what can be a lengthy treatment and recovery process requiring patience from all involved.          

Behavioural activation

A highly effective therapy which focuses on your personal schedule of activity and how it could be altered to ensure that your lifestyle is as varied and pro-active as possible.

If you have TRD, then the evidence based lifestyle advice we can offer at Priory can ensure you take steps to reduce your alcohol intake, ensuring you are getting enough sleep, and promote physical and social activity as much as possible.

Pharmacogenetic testing

This is a form of personalised medicine. We can test for the genes which are involved in response to antidepressants and in causing adverse effects. This will tell us which are the best medications to use for each individual patient. It will allow us to use the most effective medications whilst minimising adverse effects.           

In addition to the above widely used depression treatment methods, Priory can offer an innovative new treatment for depression at our new Harley Street wellbeing centre.

Rapid acting programme in depression (RAPID) by triple chronotherapy

We also able to offer another pioneering new treatment for depression at Priory Hospital North London, known as the rapid acting programme in depression (RAPID) by triple chronotherapy. This involves using light therapy whilst adjusting your sleep pattern.

This treatment method has been found to lead to a rapid response in up to 50% of patients, resulting in significant improvements in their depression symptoms after only a few days.

Electroconvulsive therapy (ECT)

This is a very effective treatment for TRD. It involves using an electric shock to induce a brief (25-30 second) seizure. It is administered under general anaesthetic, it is therefore completely painless. It is the most effective treatment for depression that is available; it works within one to two weeks. It involves having two sessions a week. It is used under close supervision in specialist ECT centres and can be administered as an inpatient and a day patient.

Repetitive transcranial magnetic stimulation (rTMS)

We are also able to offer an effective and innovative new treatment for depression at our Harley Street Wellbeing Centre. Repetitive transcranial magnetic stimulation (rTMS) is a safe and non-invasive treatment for depression which uses alternating electro-magnetic fields to stimulate the areas of your brain that are linked to mood control. rTMS is a useful treatment for depression when psychotherapy and antidepressant medication haven’t been successful, or when you are unable to take medication.

All of us feel down or sad from time to time, particularly if we experience an upsetting event such as the breakdown of a relationship or losing a job. Depression is diagnosed when these feelings of sadness persist for several weeks, which can sometimes be unrelated to your current life situation.

This debilitating condition which can affect many aspects of your life, and even make it hard to function each day, is actually highly treatable. However, TRD is diagnosed when the first line of treatment, usually involving two courses of anti-depressant medication, has failed to effectively relieve symptoms of depression, or only offers partial relief.

While there are several definitions available for TRD, which include trying up to four different treatment methods before you can be diagnosed with TRD, asking yourself the below questions can help you determine whether you need specialist treatment for depression:

• Has your treatment to date made your symptoms of depression improve?
• Do you feel as though your treatment has partially helped?
• Have you had problems with side effects when taking medication for depression?

Having TRD means that the treatment options you have been given so far to relieve symptoms of depression have not had the desired impact. If you believe that only some of your symptoms have improved, or you have had adverse reactions to medication provided, then it could be that you have TRD requiring a different treatment approach.

If you have been diagnosed with TRD, this doesn’t mean that you will have the condition for the rest of your life. While it can be difficult not to feel discouraged when months or even years pass without an effective treatment solution, many people with TRD are eventually able to recover from their symptoms and learn to effectively manage the condition.

This is made possible through structured and intensive tailored treatment programmes such as those offered here at Priory. Comprehensive treatment plans include medication, psychotherapy and revolutionary new treatments made possible through multi-disciplined team of specialist consultants, psychiatrists and therapists.

The symptoms of TRD will involve the same issues that someone living with depression would experience, although they will continue to be apparent for long periods of time, and last beyond standard methods of treating the condition, such as counselling and prescribed anti-depressant medications.

If you have been taking courses of anti-depressant medication that have not improved symptoms, it is also possible that you may have experienced side effects that can cause additional unwanted symptoms. If this is the case, then it is important to stop taking the medication in question in accordance with the guidance of the person who administered your prescription.         

When you have TRD, you would have five or more of the following symptoms of depression that either responds partially to initial treatment or not at all:

• Feeling generally depressed and of low mood for much of the day, nearly every day for a number of weeks
• Less interest in hobbies and activities you once enjoyed
• Decrease or increase in appetite
• Sleeping too much (hypersomnia) or struggling to get to sleep and stay asleep (insomnia)
• Feelings of agitation or the slowing of movements, including slowing of speech
• Excessive fatigue nearly every day, and feeling tired after even small tasks
• Struggling to think or concentrate
• Thoughts of death or suicide

If you have TRD, it can be difficult to accept when standard treatment methods such as counselling and anti-depressant medication that works for others but not for you.

This could be due to the complexity of depression as a condition, which can be different from person to person despite the similarities in symptoms. Conditions that still come under the ‘umbrella’ of depression such as bipolar disorder do not respond as well to anti-depressants as other types of the condition, while severe forms of depression and other co-existing medical and psychological disorders can make effective treatment yet more difficult.

Research into TRD has also indicated that there could be certain areas of the brain controlling expressions of sadness that may play a role in why an individual may not respond to anti-depressant medication. While anti-depressants are able to reduce how active this area of the brain is, it is believed that there are certain instances of depression where it will not respond accordingly, potentially until more appropriate medication is found.