Treatment-Resistant Depression: What It Is and How To Address It
While symptoms of depression can typically be managed with therapy, medication, or both, for some teens and young adults, it’s not always that easy. If their symptoms don’t improve over time, they may have treatment-resistant depression.
As Dr. Harry Gill, medical director of the Embark Behavioral Health outpatient clinic in Cabin John, Maryland, defines it, “It’s depression that has either not responded or only partially responded to reasonable treatment efforts for that condition.”
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How Is Treatment-Resistant Depression Diagnosed?
When it comes to identifying treatment-resistant depression, or TRD, it takes a specific type of doctor, such as a psychiatrist or otherwise qualified mental health practitioner, to diagnose a young person. A diagnosis requires that someone has tried at least two or more treatment techniques, usually medication.
“Ongoing depressive symptoms that affect daily social and personal function despite treatment with antidepressants as well as other medications indicate a young person has treatment-resistant depression,” Gill said. “We see this diagnosis in all age groups, but in my experience, it’s particularly prevalent in late adolescence given the high social pressures and maturational challenges involved in that stage of life.”
If your child is diagnosed initially with depression but no treatment has been successful, their doctor will assess their current diagnosis, which treatment options they’ve tried, and how long they’ve tried them.
Causes of Treatment-Resistant Depression
It can be hard to say exactly why some young people’s depression is difficult to treat. Reasons your child may be struggling with this issue include:
- An incorrect or incomplete diagnosis: Your teen or young adult may be experiencing symptoms similar to depression but could actually have another type of disorder, such as bipolar disorder. Or, they may have an incomplete diagnosis because other factors that affect how they feel, such as thyroid disease, have not yet been detected.
- Genetics: Your child’s genetics may contribute to how they respond to certain medications, such as antidepressants. Some medications may be less effective or even problematic for them.
- Metabolic deficiencies: Another theory, as shared in detail in Brain & Behavior Magazine, is that metabolic abnormalities can be an issue — specifically a lack of folate in cerebrospinal fluid, which surrounds the brain and spinal cord. Low levels of folate have been linked to depression.
How To Treat Treatment-Resistant Depression
Determining how to treat treatment-resistant depression depends on what your child is experiencing and why they’re experiencing it.
“Most youngsters come with symptoms of depression and anxiety,” Gill said. “However, their stories are often infinitely more complex and include early traumas, failure of social development, gender-related issues, the experience of bullying at school, and fear of the future as adults, for example. All of these experiences contribute to their depression and anxiety and need to be addressed as part of the treatment plan, which should include a combination of therapy and medication, as research has shown that to be the gold standard for treating depression.”
There are several options for helping to manage depression that’s difficult to treat.
Your child’s medication history will be important to the treatment plan. After evaluating previous and current medications’ effectiveness, a mental health provider such as a psychiatrist or psychiatric nurse practitioner may decide to:
- Give current medications more time to work. It can take up to six weeks for psychiatric medications to reach maximum effectiveness.
- Adjust the medication dosage. Typically, dosages are increased, but in some cases, a lower dosage may be best.
- Change medications. There are several types of antidepressants available, and they don’t all work the same way, so a change may be needed.
- Add a medication. More than one medication can be required to alleviate the symptoms of depression.
- Recommend pharmacogenetic testing. This type of testing is designed to identify how genetic factors affect people’s response to medications and which antidepressants and dosages may work best for them.
Therapy could be beneficial to your teen or young adult, especially if they haven’t tried it before or aren’t currently receiving it. After considering your child’s treatment history, a mental health professional may recommend they:
- Start therapy. Options include individual, family, and group therapy, and virtual counseling may be available if in-person appointments are not possible, or a virtual setting is preferred.
- Try a different type of therapy. Therapy methods used for depression include dialectical behavior therapy (DBT), a type of cognitive behavioral therapy (CBT) also known as talk therapy, and trauma-focused CBT (TF-CBT), which treats the lingering effects of trauma. Gill noted that, “Dialectical behavior therapy is particularly well suited to the adolescent mind that’s in need of a high degree of structure and guidance.”
- Switch therapists. If your child has been seeing the same person for a while or is not making enough improvement, a new therapist might be beneficial.
- Try intensive outpatient therapy. Options include an intensive outpatient program (IOP) or therapeutic day treatment program, also known as a partial hospitalization program, or PHP, both of which meet multiple times a week and include group therapy.
Regarding therapy, Gill said, “In our treatment center’s experience, group therapy is essential in the care of adolescents. This is particularly true after the pandemic isolation and extreme challenges of resocialization and disengagement caused by social media.”
There are additional treatment options for treatment-resistant depression that require professional recommendation and administration. They include:
- Transcranial magnetic stimulation (TMS): Approved by the FDA for ages 18 and older, TMS involves placing electromagnets on targeted areas of the head to create magnetic fields that stimulate the nerve cells in the brain to regulate mood. It can therefore target and treat major depressive disorder.
- Ketamine: Administered in multiple ways, including nasal spray or injection, ketamine can help activate glutamate, a chemical in the brain that’s tied to mood. It can provide an antidepressant effect more quickly than traditional medication. The FDA has approved the “s” form of ketamine, called esketamine, for treatment-resistant depression in adults.
- Electroconvulsive therapy (ECT): Administered under anesthesia, ECT involves placing electrodes on the head to deliver an electric current that causes a type of seizure, which relieves the symptoms of depression and can work more quickly than medications. The FDA has approved ECT for severe major depressive episodes associated with major depressive disorders for ages 13 and older.
Your teen or young adult’s mental health practitioner can discuss these treatment options with you and recommend whether they may help your child.
How To Support Your Child
There are several ways you can support your child if they’re experiencing treatment-resistant depression, including encouraging them to eat healthy, get enough sleep, and exercise:
Did you know mental health and gut health are connected? Sometimes referred to as the “second brain,” the gut-brain axis, or GBA, links the emotional and cognitive centers of the brain with surrounding gut functions.
A Harvard medical school article examining how food affects the way we feel offered several suggestions for a healthier gut and improved mood, including eating whole foods, fiber, seafoods, lean poultry, and fresh fruits and vegetables. The article also recommended avoiding packaged and processed foods, as they have food additives and preservatives that can disrupt healthy bacteria in the gut.
Get enough sleep
Getting enough sleep every night is crucial for adolescent bodies and minds when it comes to not only physical health but also emotional health.
So, how much sleep does your teen or young adult need to function at their best? According to the Centers for Disease Control and Prevention, teenagers ages 13-18 should get eight to 10 hours of sleep every night, while young adults ages 18 and up should get at least seven hours.
Keep in mind this should be good, quality sleep. The CDC noted signs of poor sleep include feeling tired after getting enough rest, waking up repeatedly during the night, and experiencing symptoms of sleep disorders, such as snoring or gasping for air. Have your child monitor for these issues. They may need to follow up with a doctor.
Here are a few of the CDC’s tips for getting better sleep that your teen or young adult can follow:
- Be consistent with bedtime habits by sticking to a schedule.
- Remove electronic devices, such as computers and smartphones, from the bedroom.
- Avoid eating large meals or consuming caffeine before bed.
It’s important for teens and young adults to exercise regularly. So, how much exercise do they need? According to the Physical Activities Guidelines for Americans, second edition, courtesy of the Department of Health and Human Services, children and adolescents ages 6-17 should complete about one hour or more of moderate to vigorous daily activity. Three types of exercise are most important to focus on:
- Muscle strengthening.
- Bone strengthening.
Adults 18 and older should complete at least 150 to 300 minutes a week of moderate-intensity exercise or 75 to 150 minutes a week of vigorous-intensity aerobic physical activity — or an equivalent combination of moderate- and vigorous-intensity aerobic activity.
When Depression Is Difficult To Treat
It can be discouraging for you and your teen or young adult when they’re not responding to treatment for their depression. However, although it can be difficult to get through, it’s not impossible. Mental health practitioners, which include psychiatrists and therapists, can create a plan to help your family address this challenging issue.
When it comes to specific treatment options, Gill recommended considering intensive outpatient therapy that meets multiple times a week.
“Don’t hesitate to enroll children in higher levels of care, such as intensive outpatient programs, if routine outpatient psychotherapy and psychiatric medication management are ineffective,” he said.
Embark is the most trusted name in teen and young adult mental health treatment. We’re driven to find the help your family needs. If you’re looking for support, contact us today!