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Treatment Resistant Depression

Treatment Resistant Depression

It is estimated that millions of Americans (approximately 5% of the population at any given time) suffer from major depressive disorder (MDD). In fact, approximately 15% of Americans, and 25% of American women, will experience a depressive episode in their lifetime severe enough to interfere with their ability to function.

Fortunately, most patients with MDD are able to find a treatment or series of treatments (medications/psychotherapy) that will bring about a resolution of their depression. Unfortunately, there is a significant subset of MDD who suffer from a more severe form of depression referred to as treatment resistant depression (TRD). The condition is characterized by ongoing severe depressive symptoms (decreased mood, decreased energy, appetite, disrupted sleep, feelings of hopelessness, impaired concentration among others) that fail to respond to numerous trials of psychotherapy and antidepressants. The exact percentage of patients who have this more extreme variant of depression is not known; however, recent studies estimate that it ranges from 15-30% of those suffering from depression. This means that as many as 5 million Americans suffer from TRD.

TRD is a particularly is costly in terms of disruption of life/productivity as well as costly in terms of treatment: studies suggest that the subset of those suffering with TRD place an unusually heavy burden on the overall cost of depression treatment. Further, TRD sufferers have more impairment in the home and workplace, are more likely to commit suicide, and suffer greater medical co-morbidity.

Very little is known about this subtype of depression. We know that TRD sufferers are more likely to have family members with depression.

What do studies of TRD tell us about successful treatments?

We currently know very little about what treatments work best for TRD.

A recent large-scale study of TRD (sponsored by the National Institute for Health) concluded that greater than 30% of patients suffering from depression do not respond to a series of aggressive treatment strategies.

Historically, patients who fail to respond to a series of treatments in succession would receive electroconvulsive therapy. Without question, many large, well-designed studies indicate that ECT is particularly effective at relieving TRD. However, several studies demonstrate that though ECT is very good at relieving TRD, the effectiveness of ECT tends not to be persistent. So, many TRD sufferers will slide back into depression after receiving ECT. For this reason, one of the best treatment options for TRD is to continue to receive “maintenance” ECT (treatments occurring weekly/bi-weekly to maintain the antidepressant effects of ECT).

Fortunately, new therapies, many of which are being studied at Washington University, to treat TRD.

Evolving Treatments for TRD

Vagus nerve stimulation (VNS). In 2005, the United States Food and Drug Administration approved the use of this device for the treatment of individuals suffering from depression who had failed to respond to a series of 4 or more antidepressants. This treatment works by providing a long-term electrical stimulus to the brain by using a nerve located in the neck region. Studies suggest that those patients who respond to VNS (approximately 30-35% at one year) maintain their responses at one and two years out. The fact that this appears to be a lasting treatment makes it particularly attractive option to many suffering from TRD. Current research at Washington University and other sites seeks to determine which patients with TRD are most likely to respond to this intervention.

Deep Brain Stimulation (DBS). Recent small scale studies conducted in the United States and Europe suggest that by placing very small electrical leads into deep brain tissue you can potentially bring about an antidepressant response in TRD sufferers. Thus far, these preliminary studies suggest these effects may be lasting. Ongoing studies are attempting to determine the optimal location of lead placement.

The Treatment Resistant Depression Clinic at Washington University Department of Psychiatry

In order to assist those suffering from TRD in the greater Midwest United States, the Department of Psychiatry at Washington University has a consultative TRD clinic (LINK). In order to be evaluated in the clinic, patients must have a referral from their treating psychiatrist. Full details of the clinic can be found at this link TRD.