This article is written to those with longstanding depression, which has not responded adequately to treatment.   The core message is that intensive treatment can wipe out in the most apparently stubborn cases of depression.   Do not give up!



Like most medical illnesses, most depressions are mild to moderate in severity, and most depressions resolve over a number of months, with treatment by therapy and / or medication, reducing the duration of the illness, and improving the final result.   However, about 10% of depressions become long lasting (in medical jargon, chronic illness is long lasting illness, while acute illness is short-term illness).   Vigorous intensive treatment of depression will hopefully eradicate depression before it has time to dig in.   Unfortunately, the longer depression is left without being fully eradicated, the more our brains learn to prolong the illness, or cause it to happen repeatedly, a process known as kindling.




Here are some useful tips for dealing with prolonged or chronic depression, which has been resistant to treatment.






1.Is it really depression?   


True depression is present all the time, even if it fluctuates in severity, or can be shoved into the background when nice things are happening.   True depression almost always causes impaired concentration when reading or watching TV, or impaired memory.   In contrast,unhappiness comes and goes, with the unhappy person being perfectly well for periods of time.


2.Is the person with depression particularly vulnerable?


Lack of confidence, difficulty in expressing one’s point of view, worrying about multiple issues, or being excessively perfectionistic, all predispose to depression.   Low self-esteem also predisposes to depression.   Stressful situations, especially relationship difficulties, predispose to depression.   It is necessary to simultaneously treat the illness and treat these predisposing factors to eliminate depression.


3.Selecting a therapy.


Depression is a change in a person’s chemistry caused by the stresses of life exceeding their personal vulnerability and going on to cause a wide range of symptoms.   These symptoms are usually associated with changes in the brain’s internal chemistry.


It is always necessary to offer support, counselling or more formal therapy to help the person cope better with the stresses in their lives, and with their personal vulnerability.   The standard therapies for depression have the same final aim, namely to reinforce the person’s sense of positives about themselves, and to give them strategies to understand their symptoms and see themselves as separate from the symptoms of their illness, rather than  being swept along unthinkingly by the illness.   This can be very difficult, especially when the illness is severe, or when longstanding thinking patterns are involved.


For example, anxious people need to learn relaxation techniques of whatever sort to help them stay calm, and also need to use their logic to deal with issues rather than simply worrying and panicking about them.   Perfectionist people need to think about whether or not they would actually pay an employee or a person working in their house extra money to go to the extra level of detail they strive for.   Perfectionism means a small number of things can be done to a very high standard, but trying to do everything in life to the same standard is exhausting and impossible.   We have only limited mental and physical and time resources, and we actually want a large number of things done moderately well, rather than a small number of things done extremely well, but at the cost of other tasks not getting done at all.   People who lack confidence or assertiveness as evidenced by their inability to say no to others, need discussion of the fact that we all get our feathers ruffled if someone says no to us, but we later think more highly of that person’s courage and personality if we accept in the cool light of day that the person was being fair and reasonable, rather than just being difficult.


4. Is medication relevant?


In the vast majority of cases, medication and therapy together are better than either one alone.  There is no way of predicting which antidepressant will work for any individual person, so a process of trial and error is necessary.   Antidepressants can be selected fundamentally on the basis of side-effects.   The most widely used modern antidepressants carry with them high rates of sexual side-effects and perspiration, and some risk of weight gain, especially after prolonged use.   The antidepressant Edronax is less likely to cause weight gain, or sexual side-effects, but can have a range of other side-effects, such as marked irritability and is often not effective.   The antidepressant Aurorix has very few side-effects, apart from some nausea or dizziness in hot weather, but is very weak.   The antidepressant Avanza does not have sexual side-effects or perspiration side-effects in the vast majority of people, but is very sedative with a high risk of weight gain.   The old fashioned tricyclic antidepressants (Tofranil, Anafranil, Prothiaden, Typtanol etc) are effective powerful antidepressants, with far fewer sexual side-effects, but more side-effects such as dry mouth, blurring of vision etc.


In treating resistant depression, it is useful to give the patient simultaneously medications which stop anxiety (especially the new generation of mood stabilisers or atypical antipsychotics), and older anti-anxiety agents of the benzodiazepine group (such as Valium, Serepax, Xanax etc.) which can also be very useful.


5.What do I do?


Normally, I see patients referred by other psychiatrists with depression that has not responded to treatment by them.   I choose whatever antidepressants a person has not tried before, and increase the dose of that antidepressant every 1-2 weeks while I continue to get progressive response from the person’s symptoms.    Once I have reached the maximum benefit of a particular antidepressant, as evidence by no response from the last dose increase, I then go back to the previous dose and take the next step.   The next step is either the addition of a benzodiazepine, (medications like Valium or Xanax), and / or the addition of an atypical antipsychotic.   After that, adding in a second antidepressant to supplement the benefits of the first antidepressant is often extremely useful.   Ongoing treatment then consists of ensuring the medication is at its optimum, giving the patient enough medications so that they are not anxious and so that they sleep well at night, and changing around the timing of the doses of their medication so that they get symptom relief at the best possible times of the day for their particular pattern of symptoms.   In some cases, adding in stimulant medications allows patients to tolerate high doses of antidepressants without being too medicated.   On the other hand, if the patient does become over-medicated (as indicated by yawning, trouble finding the right word or silly mistakes), reduction in dosage is necessary.   Relentless adjustment of the dose of medication to the symptoms the patient displays is very useful.


Quite apart from the medication manoeuvres outlined above, encouragement of the patient to be more assertive, to worry less, to be less obsessional and to accept positives about themselves are all very useful.   Similarly, whatever can be done to improve the person’s social interactions with others, and to improve their relationship with their partner are also very important.  


Brought to their most complex level, techniques such as described above have at times been able to help people who have been depressed for many, many years to finally get rid of their illness.   So if you have complex depression, or if a member of your family or someone close to you has complex depression, do be reminded that therapies are available which can assist them.   In rare cases, shock treatment is a dramatically effective and fast treatment for prolonged or severe depression, and is a very safe treatment, apart from some problems with memory loss, which is usually transient.   In some parts of Australia (Melbourne, Sydney, Tasmania) TMS (transcranial magnetic stimulation) is also available, requirng 20 minutes daily of exposure to the machine, and effective in 30-40% of depressions.



Important Disclaimer:  This site is medical information only, and is not to be taken as diagnosis, advice or treatment, which can only be decided by your own doctor.

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