Hello and welcome to Healthcare Magic. Thanks for your query.

Though many people respond well to anti-depressant medication, there will be a proportion of people who respond only partially or have a poor response to treatment. If there has been poor or inadequate response despite receiving an adequate dosage and duration of different classes of antidepressants, then it is likely that you may be suffering from a "treatment-resistant depression".

Now, don't get alarmed by that word as it does not imply that there is no treatment option available. It just means that these particular proportions of people need a special way of approach and management.

The management approach first involves investigating for any causes for treatment resistance, for example, certain medical causes, like thyroid problems, certain vitamin deficiencies (like B12 deficiency), etc. can be contributory. If so, they have to be detected and treated appropriately.

In your case, I would consider the following treatment options:
1) Combining an anti-psychotic medication with an anti-depressant. There are certain anti-psychotics such as Olanzapine, which have been found to have anti-depressant properties and have been recommended for the use in treatment resistant depression.
2) A combination of Venlafaxine and Mirtazapine is a very good combination (you may have tried each one individually, but combining them may potentiate each other and produce a synergistic effect). This particular combination has been specifically recommended in the UK treatment guidelines and has been proven bt research and experience, to be effective.
3) Augmenting the anti-depressant with Thyroxine (thyroid hormone) - irrespective of whether you have a thyroid problem or not. This again is proven clinically and research-wise.
4) Combination of antidepressants and mood-stabilizers. There are certain new mood stabilizers like Lamotrigine, which have a specific protective effect against recurrent depressive episodes.
5) Combining intensive psychological therapies (such as Cognitive Behavioural Therapy - CBT) with medication often gives good results.
6) Sometimes, if all medication and psychotherapy fail, Electro-convulsive Therapy (ECT) can also be used as a last resort. If you are scared about the idea of ECT, then there are alternative options like Transcranial Magnetic Stimulation (TMS) - this is very safe, does not cause any pain, discomfort or any significant side effects and can be taken without anaesthesia on an out-patient basis.

So, don't get dejected or give up hope at all. There are still many options available to tackle your 'resistant' depression. Just manage to stay afloat till your doctor is able to find her a suitable form of treatment that gives positive results. This can take some time because each option must be systematically tried before writing it off and often anti-depressant medication can take a few weeks to bring about their full potential. Do continue to have faith in the doctors treating you and you can feel free to discuss the various treatment options which I have listed above.

It is also important that you remain stress-free and stay as active as possible. Underlying stress or psychological conflicts can often be a perpetuating factor for resistant depression.

All the best.

-Dr. Jonas Sundarakumar
Consultant Psychiatrist

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Hello again XXXXXXX

I understand your concern about weight gain, due to your profession.

The following drugs do not have a significant risk of weight gain:

Anti-depressants: Reboxetine(Narebox), Desvenlafaxine (D-Veniz), Bupropion (Buprex SR)

Anti-psychotics: Aripiprazole (Arip MT), Ziprasidone (Zypsydon)

Mood stabilizers: Lamotrigine (Lamitor)

Herbal medicines: St. John's wort, Ginseng root

I would suggest that it would be worthwhile to try a combination of an anti-depressant with Lamotrigine or Aripiprazole.

Regards,
Dr. Jonas Sundarakumar
Consultant Psychiatrist

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