Treatment Resistant Depression [TRD]

Introduction To Clinical Depression

In this article, we will cover the fundamentals of TMS for Treatment Resistant Depression. First, you’ll learn more about clinical depression. Then we will discuss a more “stubborn” form of depression called TRD or Treatment-Resistant Depression. Then you will learn about the current treatments available for depression. Lastly, we will explain why TMS therapy provides hope for those suffering from treatment-resistant depression.

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What is clinical depression?

Depression is one of the worst disorders one could have. Unfortunately, depression can’t be diagnosed with a lab test or a brain scan. It is challenging to relate the silent suffering a depressed patient experiences on a daily basis. This adds more to the feeling of loneliness which is one of the symptoms of this disorder. The current DSM-V includes the following as criteria for major depressive disorder:

To diagnose a major depressive episode, the individual must be experiencing five or more symptoms during the same 2-week period and at least one of the symptoms should be either (1) depressed mood or (2) loss of interest or pleasure.

1. Depressed mood most of the day, nearly every day.
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
3. Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day.
4. Decreased sleep or excessive sleep.
5. A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day.
9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Can depression and anxiety happen together?

Depression is commonly associated with other psychiatric disorders, particularly anxiety. This warranted a subtype or a specifier of depression referred to as Major Depressive Disorder with Anxious Distress Features.

Learn more about TMS for Anxiety

The severity of Depression.

The severity of depression is broken down into mild, moderate, and severe. These quantifiers depend largely on the severity of symptoms and the functional impairment caused by depression. Functional impairment can be on one's social life (relationships, family..) or productivity (school, work..).

How serious is depression?

Contrary to the general belief, depression has a significant impact on public health. According to the World Health Organization, depression is the number one cause of disability in the world. Globally, more than 264 million people of all ages suffer from depression. Close to 800 000 people die due to suicide every year. Suicide is the second leading cause of death in 15-29-year-olds. Not only depression is a leading cause of disability worldwide but also it is a major contributor to the overall global burden of disease. There are interrelationships between depression and physical health. For example, cardiovascular disease can lead to depression, and depression can lead to worse outcomes of heart disease. The same can be said about diabetes, stroke, hypertension.. etc.

Is there a depression test?

Many depression tests had been developed over the years. The most commonly used are PHQ-9, MADRS, and HAM-D. Some of these tests are used for screening and some for follow up. Such tests are necessary to evaluate patients who could be candidates for TMS therapy.



Are women more likely to get depression than men?

Yes. Women are more likely than men to experience major depressive disorder. Women are also more likely to attempt suicide than men. That being said, men are more likely to die of suicide than women.



How to treat depression?

Mild depression is treated with psychotherapy or what is commonly referred to as talk therapy. 

Examples of effective psychotherapies include; Cognitive Behavioural Therapy (CBT), Interpersonal Therapy (IPT), Mindfulness-Based Cognitive Therapy (MBCT), and Acceptance and Commitment Therapy for Depression (ACT-D). Moderate to severe depression requires to be treated with psychotherapy as above in addition to medication antidepressants. Common antidepressants from the class of Selective Serotonin Reuptake Inhibitors or SSRIs are the first-line treatment. This includes medications like; Celexa, Lexapro, Paxil, Prozac, Zoloft. Other classes of medications include Serotonin and Norepinephrine reuptake Inhibitors or SNRIs like; Effexor, Pristiq, and Cymbalta. Some other antidepressants are used alone or in combination for augmentation with the above like; Wellbutrin, Remeron, Buspar. Also, we use mood stabilizers and antipsychotics for the reason of augmentation in some cases of severe depression like; Seroquel or Abilify.

What are the side effects of antidepressant drugs?

The list is too long and some side effects are more common in a particular antidepressant than others. The most common side effects include stomach issues, diarrhea, dry mouth, headache, dizziness, emotional numbness (feeling like a zombie), weight gain, and sexual side effects. We found that weight gain and sexual side effects to be the most common reason for patients to stop taking their medications. This could result in the worsening of the depression either because of the side effects or because of discontinuing the medication.

Learn about the pros & cons of TMS

How successful are antidepressants?

Unfortunately, antidepressants are not very successful. The success rate of antidepressants medications is about one in three. When combining medications and therapy together we may be able to get about half the patients better from the first attempt.



What happens to those who don't respond to the first attempt of antidepressants?

Those who don't respond to the first antidepressant can be tried on another. The chances of response drop significantly the more we try. To be more specific, it drops from 27% to 21% to 16% and finally to 6.9% by the fourth attempt. This means that about one-third of depressed patients are not going to respond to talk therapy and antidepressant medications. This is called Treatment Resistant Depression.



What is Treatment Resident Depression or TRD?

By CMS criteria, Treatment-Resistant Depression or TRD is commonly defined as a failure of treatment to produce response or remission for patients after two or more treatment attempts of adequate dose and duration. That being said, the definition of TRD depends on the source. In clinical trials, failure of response to one antidepressant medication is considered Treatment Resistant Depression. Lastly, some insurance companies rely on outdated guidelines from 2006 to claim their own criteria for treatment-resistant depression to be the failure of 4 antidepressants.

How to treat Treatment Resistant Depression or TRD?

There are four major treatments that are currently available for TRD. 

1. TMS or Transcranial Magnetic Stimulation.
2. ECT or Electroconvulsive Therapy. Commonly referred to as shock therapy.
3. Esketamine or S-Ketamine. A derivative of the drug; Ketamine.
4. VNS or Vagus Nerve Stimulator.

TMS is the safest option out of the four treatment options for TRD or Treatment Resistant Depression. Learn more about how TMS works in our TMS blog.