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CAPTAPsychiatry · Brian Still, MD
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Treatment-resistant depression

If two or more antidepressants have not helped enough, you are not out of options. It usually means the plan needs a closer look, not that you are beyond help.

Signs it may be time to get help

  • You have tried two or more antidepressants without enough improvement
  • You are better than you were, but still not yourself
  • Depression keeps coming back after it lifts
  • Side effects kept you from staying on a medication that was helping

How I evaluate it

I start with the basics that are often missed. Were earlier medications given at a full dose, for long enough? Is the diagnosis right? Bipolar depression, for example, needs different treatment. Are sleep apnea, thyroid problems, alcohol, chronic pain or other medications getting in the way? Bring a list of everything you have tried, with doses if you have them; we build the next step from that history.

Treatment options

  • A clear timeline of what has been tried, so the next choice is deliberate rather than another guess
  • Psychotherapy alongside medication, which improves response and lowers the chance of relapse
  • Measuring progress with standard scales such as the PHQ-9 at each visit

Options beyond the first antidepressants

Which of these makes sense depends on your history, side effects and preferences. We go through the tradeoffs together.

Getting the most from what you take now
Adjusting the dose and giving the medication a fair trial before calling it a failure.
Switching to a different mechanism
Moving to a medication that works differently, rather than a close cousin of one that already did not help.
Add-on (augmentation) medications
Adding a second medication such as bupropion, mirtazapine, aripiprazole or another FDA-approved add-on, lithium, or thyroid hormone (liothyronine). Several of these have good evidence in depression that has not responded to an antidepressant alone.
Older medications that are often overlooked
MAO inhibitors can work when newer antidepressants have not. They need dietary and drug-interaction precautions, which I explain in detail.
Treatments given in person
Esketamine nasal spray (Spravato), transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT) are among the most effective options for treatment-resistant depression. I help you decide whether one fits and coordinate with the clinic that provides it.

What telehealth can and can’t do

Esketamine, TMS and ECT are given in person at specialized clinics; I don’t prescribe controlled substances, including ketamine, by telehealth. If you are having thoughts of harming yourself and cannot keep yourself safe, call or text 988, call 911 or go to an emergency room.

This page is general information, not medical advice. Your plan is made together at your visit.