Clinical depression can be difficult to treat. But what do you do when you have treatment-resistant depression and no depression treatment seems to work?

Treatment-resistant depression (TRD) refers to depressive episodes that are not controlled by usual means of treatment. Some experts believe that TRD involves ineffective response to two "adequate trials" of antidepressant medications (of different classes). What this means is that there is not a positive response to antidepressants given for a minimum of 8-12 weeks at high enough therapeutic doses. Generally, to be called treatment resistant, it is required that there is failure to respond to two different trials of antidepressant medications of different classes (for example, SSRIs, SNRIs, tricyclic antidepressants, and others) each used at adequate doses. To review the various classes of antidepressant medications, please see appropriate areas of the HealthyPlace.com website.

Some Depression Patients Aren't Really Treatment-Resistant

One of the "flies in the ointment" when it comes to treatment of depression is that often patients do not take antidepressant medications either: long enough, or in high enough doses to be considered "an adequate trial." In my own practice, I see patients who have said they have not responded to trials of many antidepressants, but when I question them further, I find out they:

1. didn't take the depression medications long enough for them to work, or
2. they did not take the antidepressants in high enough doses to be adequate to see if they might have responded to a longer time or higher dose.

In the NIMH-sponsored Star*D trial, it was discovered that many patients do not respond to the first antidepressant they are given. From the first antidepressant to the second, third or fourth choices of treatment, the response rate goes down even further. It is usually suggested that if a patient is not responding to an antidepressant in a large enough dose for a long enough trial, then they should be tried on an antidepressant with a different way of working on the brain (a different class of medication). For example, if someone fails on an SSRI (Prozac, Zoloft, Paxil, Celexa, or Lexapro) , then it makes sense to try them on perhaps an SNRI (Effexor, Pristiq, or Cymbalta) or Wellbutrin. If they do not respond to them, other medications can either be added to the initial antidepressant (a process called augmentation with medications, such as lithium, thyroid medication, BuSpar, or other choices), or the patient can then be switched to a different class of medication, such as one of the tricyclic antidepressants (Elavil, Tofranil, Sinequan, etc.). If there is no response to the second choice of medication, others can be added or begun, or a trial of a more intensive biologic treatments (such as: shock treatments, transcranial magnetic stimulation (TMS), etc.) may be used.

In March 2009, the FDA approved Symbyax for the treatment of treatment-resistant depression. It is the first drug approved for this condition. Symbyax is a pill that combines Zyprexa (olanzapine) and Prozac (fluoxetine HCl) in a single capsule.

It is also important to note that psychotherapy for treatment of depression can be very useful instead of, or in addition to medications being used. Often it is the use of psychotherapy that can be of most benefit.

There is some data that certain nutritional supplements: such as omega-3 fatty acids, St. John's Wort, Kava Kava, and others may be helpful for some people with depression.

The key is to "do something" if the first or second antidepressants do not work. Unfortunately, although response rates are good for the initial antidepressants, there are many people who do not respond to the first or second choice.

Finally, I believe it is important that if the first or second antidepressants tried do not work adequately that a person be seen by a psychiatrist who specializes in the treatment of resistant depressions. I also believe that it is important to keep the lines of communication between patient and doctor open so that discouragement and negative mindset can be avoided.

Treatment-resistant depression can be effectively treated in most cases, but it may take time and trials of many different treatments before the best one for that patient is found. On The HealthyPlace.com TV Show this Tuesday night (April 21 at 7:30p CT, 8:30 ET), we will discuss the topic of treatment-resistant depression even further. I hope you'll join us.

I also want to recommend that you read The Gold Standard for Treating Depression. You will find authoritative information on all aspects of depression treatment.

Dr. Harry Croft is a Board-Certified Psychiatrist and Medical Director of HealthyPlace.com. Dr. Croft is also the co-host of the HealthyPlace TV Show.

next: How to Manage Your Panic Attacks
~ other mental health articles by Dr. Croft

Here's what's happening on the HealthyPlace site this week:

• Prescription Assistance
• "Managing Your Panic Attacks" On HealthyPlace TV
• Follow-up on the 'Dear Dad' Letter
• Additional Insights on Abuse
• Are You Interested in Alternative Mental Health Treatments?

Prescription Assistance

With the economy in bad shape, many with mental health concerns write us asking where they can get help with paying for their psychiatric medications and mental health services (this link is a table of contents page listing every article we have on the subject). We have two major sections on the site that address those issues:

1. Free or Low-Cost Prescription Medication Assistance
2. Finding and Paying for Mental Health Treatment
   

"Managing Your Panic Attacks" On HealthyPlace TV

Our guests successfully overcame their debilitating panic attacks. Find out how. Share your opinion and get insight into effective ways to treat panic disorder, panic attacks from our Medical Director, Dr. Harry Croft.

This Tuesday night, April 14. The show starts at 5:30p PT, 7:30 CT, 8:30 ET and airs live on our website.

• TV Show Blog with this week's show info
• Dr. Harry Croft's blog post on "How to Manage Your Panic Attacks"
• Symptoms of a panic attack, how to identify panic disorder, what causes panic disorder, treatment for panic disorder and Panic Disorder self-test.
• Click here for a list of previous HealthyPlace Mental Health TV Shows.

In the second half of the show, you get to ask Dr. Harry Croft, your personal mental health questions.

Follow-up to 'Dear Dad Letter'

Last week's personal story from Roberta Hart, detailing her experiences with child abuse and the impact it had on her, compelled many people to write in and share their thoughts.

Maryann: "Similar to Roberta, I witnessed my mother sexually abusing my brother. I was 13 at the time and was afraid and didn't know what to do. Today, I live with the guilt of my brother's suicide at the age of 22."

DeeDee: "I'm writing to tell you that some "letters to abusers" end up causing more harm than good. I wrote a 5 page letter to my abuser who was still alive at the time. Instead of an apology, I got a lot of denial and my parents and brothers refuse to even talk to me. I'm a complete outcast in my family and to tell you the truth, I feel very alone and wish I hadn't written that letter."

And finally, this note from Michael: "Regretfully, I'm like Roberta Hart's father, an alcoholic who stole my daughter's childhood. I am in recovery, but I will never be able to recover from the pain and suffering that I have caused. Every day, it is difficult for me to live with what I have done."

Additional Insights on Abuse

1. How Child Abuse Affects Children
2. How Does Physical Abuse Impact A Child?
3. Impact of Psychological Abuse on Children's Mental Health and Emotional Well-being
4. Adults Sexually Abused as Children (Adult Survivors of Child Sexual Abuse)
5. Reporting Child Abuse
6. All HealthyPlace Articles on Abuse

Are You Interested in Alternative Mental Health Treatments?

Many people are. The National Institute of Health reports over 30% of people with psychiatric disorders have tried alternative mental health treatments from diet and nutrition to self-help and various types of therapies.  In the HealthyPlace Alternative Mental Health Community, we have comprehensive information on alternative treatments for mental health conditions including:

• Addictions
• Alzheimer's
• ADHD
• Anxiety and panic
• Bipolar disorder
• Depression
• Eating disorders and more

back to: HealthyPlace.com Mental-Health Newsletter Index

Find out what causes panic attacks and how panic attacks can be treated before they take over your life.

Panic attacks are truly frightening events. Your heart races, you can't catch your breath. You feel dizzy, your stomach hurts, your mouth is dry. You feel like you're going to die or go crazy.

What Causes A Panic Attack?

The attacks come on quite quickly and peak within just a few minutes, often disappearing as suddenly as they appeared. Sometimes panic attacks are provoked by events going on around you, but sometimes they "come out of the blue" and arise for no reason at all. They may even wake you up out of your sleep.

The belief is that these panic attacks are caused by, or result from, the "misfiring" of the parts of the brain designed to alert us to things around us that might harm us (the "fight or flight" reaction that most of us have heard about). The misfiring refers to the fact that although the panic attack symptoms appear, there is no apparent danger facing us.

In addition to the attacks themselves, people suffering from panic disorder often have other symptoms including "anticipatory anxiety"- that is worry about the occurrence of the next attack. Since these attacks generally occur "somewhere," often the person suffering panic attacks may begin to avoid those areas where the attacks have previously appeared (agoraphobia). This may involve avoiding people, places, and things that have been known to be associated with panic attacks, and this results in a change in daily activities as a result of the attacks.

Panic Attack or Medical Problem

The tragedy is that many suffering from panic attacks often misinterpret the panic attack symptoms as being the result of some medical problem—such as heart attack, stomach, neurologic or other type medical problem. Often the patient ends up in the emergency room as a result of their panic attacks. During the time it takes to do the "workup" in the ER, the symptoms often resolve, and so when the doctor reports, "We can't find any medical cause for your symptoms and I think you're having a panic attack," the sufferer no longer is concerned, accepts the results and leaves. The problem is that, at the time of the next attack, the sufferer is in "the same boat" with regard to uncertainty about the cause of their symptoms. Often it is years before the correct diagnosis is made and accepted by the patient.

Medication and Therapy for Treatment of Panic Attacks

In general, the most effective treatment of panic attacks involves:

• education about panic disorder
• therapy aimed at controlling the response to the panic attacks
• medication to control and prevent recurrent panic attacks
• other types of treatment

The most important part of panic attack treatment involves understanding what the attacks are, that the symptoms really represent "a panic attack." It often takes years of suffering from the attacks before the patient gets to this point. Educational information about panic attacks can be found on the HealthyPlace website. Psychotherapy treatment for panic attacks and panic disorder generally involves:

• behavioral therapy aimed at learning to relax and control the symptoms of the panic attack
• cognitive behavioral approaches aimed at lessening the impact of the attack ("What's the worst thing that will happen?")
• relaxation exercises

The medication treatment for panic attacks involves two different approaches:

1. tranquilizers aimed at reducing the symptoms of the attack when they appear; and
2. other medications to reduce or prevent the recurrence of the panic attacks.

The first panic attack treatment involves the use of tranquilizers (usually "benzodiazepines"such as Xanax, Ativan, or Klonopin). This is, however, at best a "short-term approach." The longer-term, and more appropriate preventative approach, generally involves the use of serotonin-increasing "antidepressants" (such as the SSRIs (Prozac, , Paxil, Celexa, Lexapro-- or SNRIs such as Effexor or Cymbalta). Other medications may prove effective as well. To find a list of all anxiety medications approved and useful for panic attacks, please see other areas of this website.

There are nutritional approaches that have been suggested for panic attacks, but none of these have proven to be effective for most sufferers of the attacks.

This Tuesday, April 14, on HealthyPlace TV, we'll be going into more detail on the symptoms and treatments for this interesting and potentially disabling disorder. We hope you'll join us for the live show. If not, click the "on-demand" button on the player to watch the replay.

Dr. Harry Croft is a Board-Certified Psychiatrist and Medical Director of HealthyPlace.com. Dr. Croft is also the co-host of the HealthyPlace TV Show.

next: Treatment of Children with ADHD
~ other mental health articles by Dr. Croft

                                         THE PERSON THAT HAS A VERY UNUSAL MOODS DAILY.

IF NOT RIGHT NOW I FEEL LIKE A PERSON THAT HAS A CARE IN THE WORLD AND I FEEL LIKE THAT ALL THE TIME AND I HAVE A VERY SEVERE ANGER PROBLEM WITH A PERSON THAT I WANT TO LITERRALLY WANT TO HUR T BAD AND I HAVE ALOT OF HATRED IN ME  RIGHT NOW AND I CANT CHANGE THAT.

I was a part of healthy place, many years ago now, and found it extremely helpful.  I fell away as other parts of life had my attention (raising my son, watching my partner go from bing drinking to getting sober - 2 1/2 years now and am incredible proud of him).  Diagnosised with bi-polar over 12 years ago and now, although the med's I use are keeping things on a somewhat even keel, I am prone to incredible amounts of depression.  This last bout has lasted over a month and now I have decided I needed a break from the...kaos of day to day at home.  I am leaving on Monday to spend time away - 5 days - to try and prioritize what in my life is needed.

Not certain how this is going to work through, I just know that a break is needed.  I think that speaking with others that have, or are going through, the same type of bouts would help immensely - help to pull me out of the dark hole I find myself in.  The next week is suppose to be beautiful - sunny and spring temperatures.  Shall try and get out and soak up rays as I realize the importance of light and fresh air.

Beautiful Stitches

By Melinda Lea Tharpe

October 23, 2007

How can I start

With a life unraveling?

Beautiful stitches

Falling to the floor,

Unlooping and piling,

No longer forming,

Needing hands to create

Again

What was enamored.

Spooling and tearful

I gather up what was

And give to you,

An auspicious gift

To be reanimated

With heartening hands.