Depression

Chronically Depressed? What to Do When Antidepressants Don’t Work

Chronically Depressed? What to Do When Antidepressants Don’t Work

The range of options includes cognitive behavioral therapy and brain stimulation techniques like ECT

By SARAH BALDAUF
Posted: November 6, 2009
 
  Last winter, confined to bed by intense sadness, exhaustion, and headaches, the University of Kansas student found herself considering suicide. Desperate after a years-long struggle with depression, she sought a treatment she had once viewed as extreme: electroconvulsive therapy. After a few sessions, “I literally went from almost unable to function—feeling suicidal—to a 180-degree change,” she says.

Chronically Depressed? What to Do When Antidepressants Don’t Work

The range of options includes cognitive behavioral therapy and brain stimulation techniques like ECT

By SARAH BALDAUF
Posted: November 6, 2009
 
  Last winter, confined to bed by intense sadness, exhaustion, and headaches, the University of Kansas student found herself considering suicide. Desperate after a years-long struggle with depression, she sought a treatment she had once viewed as extreme: electroconvulsive therapy. After a few sessions, “I literally went from almost unable to function—feeling suicidal—to a 180-degree change,” she says.

The student, who still contends with depression, is one of the many people chronically in its grip who, disappointed by antidepressants, are finding some relief in therapies ranging from exercise to various forms of high-tech brain stimulation. Some 27 million Americans were taking an antidepressant in 2005, more than twice the number almost 10 years earlier, thanks largely to the arrival of Prozac and other effective antidepressants with fewer side effects. But a groundbreaking 2006 trial known as STAR*D revealed that about one third of people found total relief with their first drug, and around a third were not helped even after trying several drugs and combinations. ECT, which has been controversial since the days when it was performed without anesthesia and sometimes without proper consent, has evolved considerably in recent years; by inducing a seizure, it is thought to reset dysfunctional brain circuitry. It “is the most effective and rapidly acting treatment for severe depression,” says Sarah Lisanby, a professor of clinical psychiatry at Columbia University Medical Center who is a leading brain stimulation researcher.
Because ECT is an invasive therapy that involves anesthesia and often memory loss, people suffering from unrelenting depression are steered to other approaches first. These might include continued medication—though getting a response can take considerable work. Steven Hollon, professor of psychology and a depression researcher at Vanderbilt University, is concerned that family practitioners, who have become much more comfortable writing prescriptions for the newer antidepressants, don’t offer enough follow-up. It can take six weeks for an antidepressant to kick in; many people simply give up, especially if the new drug comes with, say, headaches or an upset stomach. “That can be asking a lot of a person,” says Matthew Rudorfer, psychiatrist and associate director for treatment research at the National Institute of Mental Health. It may well be, he says, that side effects would subside, or that switching drugs or adding a second one can work.
[Brain Stimulation: Can It Help You?]
Add therapy? Or perhaps a dose of therapy is called for. An August report in Archives of General Psychiatry revealed that people on antidepressants are less likely to also be in therapy than they once were—about 20 percent in 2005, down from nearly 32 percent in 1996. But some evidence suggests that chronic depression may respond more readily to medication plus therapy than to either alone. And one arm of the STAR*D trial showed that turning to cognitive behavioral therapy after a first drug fails works about as well as trying a second medication.
This particular brand of talk therapy doesn’t take a Freudian look back into your childhood. Rather, it focuses tightly on correcting the negative or catastrophic thought patterns (“I’m such a failure,” “I’m not worthy of being loved”) that so often stoke depression. The concept is supported by an increasingly robust body of research. Moreover, some intriguing work in neuro imaging has shown that CBT “not only works to relieve symptoms but is also associated with brain function changes,” says Madhukar Trivedi, a lead researcher on STAR*D and a professor of psychiatry at University of Texas Southwestern Medical School.
Clearly, the way we think matters. “In a depressed person’s mind, thoughts tend to be overly pessimistic, overly harsh in regard to how the world works,” explains Robert DeRubeis, a psychologist and a depression and CBT researcher at the University of Pennsylvania. “Our behaviors follow from the judgments we make” and often just deepen feelings of woe. A depressed person may decide not to attend a party, for example, because he believes no one will talk to him. But with a therapist’s probing, he might examine how realistic that belief is and realize he has the power to start the conversational ball rolling. Some research suggests CBT may have a more lasting effect than antidepressants after treatment ends, perhaps because people have mastered the strategies that keep them from getting depressed, says Hollon.
It’s important to find a well-trained cognitive behavioral therapist. A 2005 study by DeRubeis and Hollon compared 16 weeks of drugs, CBT, and a placebo and found a response rate of 58 percent in both the drug and CBT groups—but also that the level of therapist expertise might affect CBT’s success rate. How best to find a practitioner? Start by inquiring at a nearby academic medical center or by searching the Academy of Cognitive Therapy’s website. And give it two to five sessions before doing a gut check, says Hollon.
The Kansas student, who has battled depression—the dominant feature of her bipolar disorder—since childhood, had been in therapy and on a range of drugs before inquiring about ECT. As is typical, she started out with several ECT sessions per week. She tapered down to about one per month and ended treatments in June after about six months. She has felt well enough to be back in class, hold down an internship, and glean joy from darkroom photography and time with friends.
Short-term memory loss is the main concern with ECT, and it’s not uncommon. The effect usually wears off after treatment ends, but some information may never return—that graduation ceremony you attended between sessions, for example. The student recalls struggling to remember a relative’s name and still has to make lists for the grocery store and to rely on a daily planner, though she needed neither before ECT.
Some patients claim to have experienced far longer-lasting problems, which may be a consequence, say, of receiving more current than was necessary. ECT has changed significantly as understanding has grown about how to minimize memory side effects, says Rudorfer. He says that it “has much lower risk than decades ago—though the risk is not zero.” Technique matters, including an ability to reach just the amount of electrical current needed to induce seizures, which can differ among patients; the placement of the electrodes on the head; and the type of stimulation used (brief or ultrabrief pulse causes the fewest cognitive deficits; an older type, sine wave stimulation, significantly more). Cognitive problems are considerably less pronounced when the electrodes are put on one side of the head instead of both, but the one-sided approach is not as effective in some people. Critics of ECT have insisted that it causes brain injury, but studies in humans and animals have not corroborated the claim, says Rudorfer.
Another caveat: The benefits don’t necessarily last. One study showed that 84 percent of patients had relapsed six months after the treatments ended without any “maintenance therapy” (drugs—which may help after ECT even if they failed before—or less frequent ECT sessions). Still, other research has shown that after a successful course of ECT with some form of maintenance therapy, about 46 percent of patients remained well six months out. The college student now tries to manage her recurring depression with a combination of therapy, medication, and lifestyle changes—more exercise and sleep, light exposure, and taking fish-oil supplements—that she learned about from The Depression Cure: The 6-Step Program to Beat Depression Without Drugs, a book by her psychology professor at Kansas, Stephen Ilardi. “It might be attributable to other things, but I really feel like some of these [lifestyle changes] have been helping,” she says.
[Read more about how lifestyle changes might help when you’re depressed.]
Moving. Indeed, a growing body of research suggests that regular exercise, at least, might be a smart prescription to try—or to add to drugs or therapy. It appears to promote a good, stable mood by reinforcing self-confidence and a sense of control over one’s health, says Andrea Dunn, a Colorado behavioral science researcher and a principal investigator for a pilot study exploring the impact of regular exercise on depressed adolescents. A possible mechanism: Exercise creates new neurons, she says, bolstering connectivity in the depressed brain, which often operates with a deficit of connections.
The oft-quoted success rate for electroconvulsive therapy—that it brings remission to 80 percent of people who try it—was arrived at under the rigorous setting of a clinical trial. A 2004 study of ECT success rates in the community hospital setting put the number between 30 percent and 47 percent. The discrepancy probably reflects variation in doctors’ techniques, additional complicating illnesses, and the fact that some patients stop ECT early because of side effects, says Lisanby.
In the face of ECT’s shortcomings, newer brain-stimulation treatments are being explored. But none are widely available, and how well each works and for whom is not yet known. Transcranial magnetic stimulation, which has been cleared by the Food and Drug Administration for depression, targets neurons in areas of the brain involved in mood by placing a magnetic coil on the head. Unlike ECT, it does not result in a seizure or require anesthesia, nor does it cause memory loss. But it is hardly available in every community and may not work well for patients with more severe cases. In vagus nerve stimulation, a device surgically implanted in the chest stimulates the brain by shooting electrical pulses into the vagus nerve in the neck. “To many in the field, the jury is still out” on its effectiveness, says Rudorfer. Deep brain stimulation, approved for movement disorders, including Parkinson’s disease, is available for depression only in research trials. It involves surgery to place electrodes into the brain and a small battery pack in the chest. The good news, says Rudorfer, is that most people will respond to a mainstream treatment—as long as they persevere.
[Read how Mark George is treating depression with an electromagnet.]
Copyright © 2011 U.S.News & World Report

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