Psychiatrists explain why persistent depression calls for a treatment review

A lack of improvement with an antidepressant calls for a review of diagnosis and treatment rather than an automatic finding of treatment-resistant depression, Chennai psychiatrists told The Hindu in an October 10 report.

The report describes a 32-year-old Kerala resident identified by the changed name Priya. Recurrent depression disrupted her everyday activities, and several weeks of medication did not resolve her symptoms. After seeking further advice, she began repetitive transcranial magnetic stimulation, or rTMS.

Treatment resistance is generally considered after an inadequate response to at least two antidepressants, each taken at an appropriate dose for sufficient time, usually six to eight weeks. The report cites an estimate of about 30% among people with major depressive disorder who have tried antidepressants. India’s National Mental Health Survey estimated lifetime adult prevalence of depressive disorders at 5.25% and current prevalence at 2.68%.

Venkatesh Madankumar of Prashanth Hospitals stressed checking missed doses, insufficient dosage or treatment duration, side effects, drug interactions and coexisting illness. Alternative diagnoses, especially bipolar disorder, also need consideration because they require a different approach.

Vivian Kapil of SRM Prime Hospital highlighted assessment for substance use, psychotic symptoms, post-traumatic stress disorder and other conditions. Anaemia and thyroid disorders can contribute to symptoms or complicate care. Depression itself can affect sleep, appetite, concentration, work and relationships alongside mood and loss of interest.

Doctors select the next step according to response and tolerability. Partial improvement may prompt a dosage review, while little benefit after an adequate trial may lead to a different antidepressant. Medication combinations and psychotherapy, particularly cognitive behavioural therapy, are other options. Additional medicines require specialist monitoring.

Ketamine and esketamine may be considered in selected cases when a faster response is important. Some patients improve within hours or days, but the degree and durability of benefit vary. Dizziness, nausea, raised blood pressure and temporary changes in perception are possible, making medical supervision necessary.

Electroconvulsive therapy, or ECT, may be considered for severe depression, unsuccessful prior treatment or an urgent need for care. Examples include a high suicide risk, loss of contact with reality or an inability to eat or drink adequately. ECT uses anaesthesia. Headaches, temporary confusion and memory difficulties are possible effects.

Vasanth R. of Apollo Speciality Hospitals described rTMS as using magnetic pulses directed at brain regions involved in mood regulation. Unlike ECT, it does not require general anaesthesia and the patient remains awake. Outpatient sessions usually continue over several weeks. Availability varies between Indian centres, while cost and repeated visits can affect access.

The extent and timing of benefit from rTMS differ between patients, and returning symptoms may require further treatment. Scalp discomfort and headaches are possible, with seizures a rare recognised risk. Assessment includes medical history, seizure risk and implanted metal or electronic devices. The specialists also mentioned vagus nerve stimulation, or VNS. The choice depends on clinical condition and previous treatment response.