Treatment-resistant depression
Treatment-resistant depression (TRD) is a term used to refer to depression that has not improved enough after two or more antidepressants taken for long enough at a sufficient dose. About 1 in 3 patients with depression experience TRD. Fortunately, we have many options that can make a difference, even if the first choices haven't.
Signs of treatment-resistant depression
You might have TRD if:
- You have felt bad or pessimistic about life for a long time
- You are often not able to enjoy things in your day to day life
- You have tried two antidepressants at a therapeutic dose for at least several weeks each
- Your symptoms are not better explained by a different mental health issue
How BPA doctors approach treatment-resistant depression
Our first step is making sure the diagnosis is correct. For example, bipolar depression is sometimes a better explanation of your symptoms and, if present, can point us in the direction of different treatments that might be more useful. Other factors, like substance use or insomnia, can also get in the way of recovering from depression and our doctors can help you with these issues as well.
The next step is discussing which treatment options make the most sense for you to move forward with. This can include a number of different medications that often don't get thought about at first. It can also include adding or optimizing psychotherapy. Some of the most powerful treatments for depression are what we call interventional treatments, discussed below.
What are interventional treatments and what role do they play in TRD?
Simply put, interventional treatments are treatments that you come to the clinic to receive and that you do not take every day. This includes ketamine and Spravato, TMS, and ECT, all of which BPA offers. While nothing works for everyone, interventional treatments can and frequently do alleviate symptoms even when many other forms of care haven't. You can read more about what these treatments are like below and on other pages on our site.
How do I get started with care?
If you do not yet have a regular psychiatrist or want to establish a relationship with a new one to discuss your care in general, consider requesting a general outpatient care intake. If you already know you are looking for interventional treatment, you can get started right away with an intake with one of our doctors specializing in TMS, ketamine/Spravato, or ECT. As you are filling out the intake form, select the option that you think makes most sense; our staff will always reach out to answer any questions before the intake is scheduled.
Regardless of which option you choose, care starts with an hour-long conversation with one of our psychiatrists to discuss your history, talk about what each treatment is like and answer any other questions you have.
Interventional treatments at a glance
| TMS | Spravato / IM & IV ketamine | ECT | |
|---|---|---|---|
| Anesthesia | No | No | Yes (brief) |
| Where | BPA office | Comfortable private treatment room at a BPA office | Herrick Hospital |
| Time per visit | ~20–30 min | ~2+ hours | ~1 hour incl. recovery |
| Typical course | ~6 weeks (about 36 sessions) | 3 to 8 weeks initially, depending on route | 6–12 treatments |
| Speed of response | Often weeks 3–4 | Hours to days for some | Often within 1–2 weeks |
| Memory effects | None expected | None expected | Possible, usually temporary |
What to expect over time
With interventional treatments, patients sometimes can experience significant improvement over the course of the first couple of weeks. For others, recovery can take longer.
As many patients with TRD know, depression can be a lifelong struggle which comes and goes. An important aspect of your care for TRD therefore is thinking about how to make the benefit you experience stick. Fortunately, there are evidence-based ways to reduce your risk of recurrence of depression, such as certain medication strategies, psychotherapy or lifestyle changes. Our doctors collaborate with you to make a plan that keeps you well over the long term.
How we treat treatment-resistant depression
Transcranial Magnetic Stimulation (TMS)
A non-invasive treatment for depression and OCD for patients who have not improved enough with medications, psychotherapy or both.
Ketamine therapy
Ketamine is a rapidly acting treatment for depression that works differently from traditional antidepressants and may help people whose depression has not improved enough with medications and psychotherapy.
Electroconvulsive therapy (ECT)
A highly effective treatment for severe or treatment-resistant depression and other conditions, given under brief general anesthesia with full medical monitoring.
BPA clinicians treat the full range of treatment-resistant depression
Every clinician at Bay Psychiatric Associates evaluates and treats treatment-resistant depression. We match you by availability, location, and fit, not by narrowing you to a short list. Here are all 38 clinicians, in alphabetical order, practicing across our Bay Area offices.
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- Anthony DiGiovanni, MD
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- Karen Marcus, MD
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Common questions about treatment-resistant depression
How do I know if I have treatment-resistant depression?
It is typically considered when two or more adequate antidepressant trials, the right medication, dose, and duration, have not produced enough improvement. Part of a consultation is reviewing prior treatment for adequacy, since an apparent non-response is sometimes an under-dosed or short trial.
Which option should I choose, TMS, ketamine, or ECT?
There is no single right answer and some patients are better fits for one treatment than others. Factors our doctors will discuss with you that can help inform the decision include things like the history of your depression symptoms, other psychiatric or medical issues you may be experiencing, and logistical concerns that can impact how easy it is for you to receive the treatment you choose.
Will my insurance cover these treatments?
TMS, Spravato, and ECT are covered by most major insurers, generally with prior authorization. Insurance coverage for IM and IV ketamine varies by plan, because these treatments are "off-label". Our staff will verify your plan and give you a clear cost estimate before you get started with any of these.
Will I need to stop my current medications?
Usually no. Most medications are compatible with interventional treatments and are usually continued. BPA's interventional psychiatrists are experts in questions about how interventional treatments interact with regular medications and will assess your full regimen before starting treatment.
Let's match you to the right care
Your first visit is typically an hour-long evaluation. By the end, you leave with a working diagnosis and a treatment plan you feel confident in.