Sadly, not everyone who gets depressed
gets better with medication treatment.
We call this treatment resistance.
It's a frustrating situation to deal with,
but there are things that can make you treatment resistant
that are changeable.
That's what I'm talking about today.
I'm Dr. Tracey Marks, a psychiatrist,
and I make mental health education videos.
There was a landmark study from 2006
called the STAR*D trial,
which stands for Sequenced Treatment Alternatives
to Relieve Depression.
I won't go into details of the study,
because there's lots that came out of it.
But suffice it to say that it was a huge trial
with lots of people enrolled and was designed to see
how well our antidepressant treatments work.
The study included four treatment stages
that included medication switches and add-on agents.
If the first one didn't work,
you moved on to a different medication
or got something added to your medication,
and that's pretty much how we do things in practice.
If one doesn't work at all, we switch to another.
If it partially works,
we may add something to boost the effectiveness.
This is called augmenting the medication.
The study found that only a third of people
achieved remission from the first antidepressant,
remission being a resolution of your symptoms.
It took six weeks to see some response,
and then seven weeks to achieve remission.
Of the people who went through all four steps,
only 67% of those people achieved remission.
So what does this mean practically?
There's a lot of people who fall
into the treatment-resistant category.
In practice, treatment resistance is defined
as failing to adequately respond
to two trials of an antidepressant.
It's important to understand that treatment resistance
is not the same as medication intolerance.
You can stop a medication after a few days
because of side effects, and if that happens,
the trial of that medication
doesn't count as a medication failure
when it comes to looking at treatment resistance,
because of side effects,
you weren't able to see if the medication
would've helped your depression symptoms.
Another caveat here is before you consider
the medication a failure,
you have to give it enough time.
In this study, it took up to seven weeks
for people's depression to resolve.
Why does it take so long?
Two factors, one is therapeutic response
requires you to take a dose that's in a range
that's high enough to work.
This is called the therapeutic range.
Oftentimes, your doctor will start you at a low dose
and gradually work you up to the therapeutic range.
The second factor is
once you've reached the therapeutic range,
your brain receptors and circuitry
need time to respond and adjust.
Then, the emotional improvement follows.
Let's say you have tried and failed to respond
to two or even three different medication strategies,
or you have some improvement
but it's not enough and you're still pretty depressed,
we call this a partial response.
Here are some physical conditions that can,
in their own right,
cause depression symptoms
making it hard for your depression
to resolve from antidepressants alone,
hormone imbalances, like hypothyroidism,
low testosterone and low estrogen.
In all of these cases, hormone supplementation
can improve your mood symptoms.
In fact, sometimes we will use thyroid supplementation
as an augmenting strategy to treat depression,
even in someone who has normal thyroid levels.
Chronic pain syndromes can cause depression
in people who don't have a history of being depressed.
So if you're already depressed and have chronic pain
that's inadequately treated,
that daily pain experience
can negatively impact your response to antidepressants.
There's a very strong link
between fibromyalgia and depression,
such that many people have both.
It's no coincidence that the antidepressant duloxetine,
brand name Cymbalta, is prescribed to treat both conditions.
If you have ever had a stroke or heart attack,
you're at greater risk of developing depression.
A stroke can result in personality changes
that can mimic depression,
so it can seem like you're not bouncing back
to your old self,
because you're more irritable and emotionally labile.
Sometimes a mood stabilizer can help your symptoms
more than the antidepressant alone.
So in all of these cases, looking past psychological causes
may give you the answer as to why you're not getting better.
Then, the next thing to look
at is your entire medication regimen.
What medications are you taking for other conditions?
Some medications have depression as a side effect.
Taking an antidepressant
doesn't necessarily offset that effect.
A 2018 study showed a multiplier effect
if you take more than one medication
that has depression as a side effect,
so the more you take,
the greater the risk of becoming depressed
or having your depression
be harder to treat with antidepressants.
Here are some of the medications
that can cause depression as a side effect.
It's a fairly long list,
and I'll have a handout for you that you can download
from my website.
Here are a few of them, acid reflux medications,
examples are omeprazole, ranitidine, and famotidine;
allergy medications, like montelukast,
which is Singulair,
or cetirizine, which is Zyrtec;
anxiety medications, mostly the benzodiazepines,
like alprazolam, diazepam, and lorazepam,
even zolpidem for sleep, has this potential;
birth control and hormone therapy containing estrogen;
some blood pressure medications,
like atenolol, metoprolol, and enalapril;
pain medications, like ibuprofen,
cyclobenzaprine, hydrocodone, and tramadol.
And then, there's antiseizure medications,
like gabapentin, topiramate, and lamotrigine.
Now, you may have been on one
or some of these medications for years,
it's not a guarantee that you will experience depression
as a side effect if you take any of these.
All medications have a long list of potential side effects,
and some people get several of the effects
and some people experience none.
So I don't want you to think
that you can't take any of these medications.
The learning point here is that these medications
carry a risk of causing depression,
and the more you take, the greater the risk.
And if you have depression that is not improving enough
with your current antidepressant treatment regimen,
one thing you and your doctor can do
is take a look at whatever else you're taking
and see if you can take alternative medications
that don't carry the risk of causing depression.
A couple of these medications I mentioned
are over the counter, like ibuprofen and Zyrtec.
If you want to consider some nonprescription
medication options for depression,
take a look at this video,
and this other one about ketamine
is one of the premium solutions
for treatment-resistant depression.
Thanks for watching, see you next time.