Depression
Treatment-resistant depression: when antidepressants have not worked
If you have been through several medications, a course or two of therapy and a long wait for each, you have probably been told to keep going. There are options that are not another prescription.
Treatment resistance
The part that rarely gets said out loud
You have tried more than one antidepressant. Perhaps one helped a little, or helped for a while and then stopped. Perhaps the side effects were worse than the improvement. Perhaps you were told to give it another six weeks, and then another six weeks after that.
Somewhere in the third or fourth attempt, something shifts. You stop expecting treatment to work. You keep taking the tablets because stopping seems worse, and you learn to describe yourself as someone who has tried everything.
That is not a failure of effort, yours or your doctor’s. It is what the standard pathway looks like when it does not happen to work for you. The pathway assumes that if one drug does not suit you the next one might, and for most people that is true. When it is not, the pathway runs out of ideas long before you do.
Definition
Two adequate trials, without an adequate response
Depression is usually called treatment resistant when at least two antidepressants, each taken at a proper dose for long enough, have not produced enough improvement.
It is a description of what has happened so far, not a verdict. It does not mean your depression is untreatable, and it does not mean you have a more severe illness than someone who responded to the first thing they tried. It means the treatments tried so far were not the right ones for you.
What we can offer
Three things, and they are not alternatives to each other
Deep TMS
A non-invasive treatment that uses magnetic pulses to stimulate the brain networks involved in depression. You sit in a chair, awake, for about half an hour. Nothing to take, and no recovery time.
In a head-to-head trial, two-thirds of people with treatment-resistant depression responded to Deep TMS, against under a quarter of those on medication alone.
Pharmacogenetic testing
A cheek swab that shows how your body metabolises psychiatric medication. If you have had unusual side effects, or a drug that seemed to do nothing at full dose, this can tell you whether the problem was the drug or the dose.
It will not tell you which medication will work, and we will say so.
A consultant assessment
An hour with Dr Nabavi, going through what you have actually tried and what happened each time. For many people this is the first time anyone has looked at the whole history in one sitting.
It is also where you find out whether either of the above applies to you.
That is what the assessment is for
You do not need to work this out before you contact us, and we would rather you did not try.
Broadly: if medication has caused unusual reactions or has never seemed to do anything, testing is worth considering first. If medication has been given a fair run and has simply not been enough, Deep TMS is the more likely recommendation. Plenty of people end up doing both.
An assessment costs £400, and if you go on to have Deep TMS here, that £400 comes off the cost of treatment.
Alongside
You do not have to stop what you are already doing
You can keep taking your medication. You can keep seeing your therapist. Deep TMS was studied as an addition to standard treatment rather than a substitute for it, and that is how we use it.
You also stay under your own GP or psychiatrist. We write to them with what we find and what we do, and when your course finishes you go back to them. We are not asking you to move your care.
What a course looks like
Five sessions a week for four weeks, then two a week for a further eight: 36 sessions over about three months. There is also an accelerated protocol that compresses the whole thing into about two weeks.
When you would know
Most people notice a change around the twentieth session. Your symptoms are scored on the same validated scales at set points, so you can see the change in the scores, not just feel it.
Your medication continues
Any change to your prescription is a decision for you and whoever prescribes it.
Common questions
No. You can contact us directly. We will usually ask to keep your GP informed.
Some people do not respond, and we will tell you plainly rather than keep you coming. Depending on what we find, there may be another protocol worth trying, or testing worth doing, or a clear recommendation to take back to your own psychiatrist. An honest answer is more useful than another course of something that is not working.
ECT is given under general anaesthetic and deliberately induces a seizure. Deep TMS does neither. You stay awake, you drive yourself home, and there is none of the memory disturbance associated with ECT.
Rarely. A small number of NHS services in England offer TMS, including one in Birmingham, but access is limited and waiting lists are long. Most people who have it in the UK have it privately.
The assessment is £400, credited against treatment if you proceed. Deep TMS is £250 a session. The number of sessions depends on your protocol, and we set out the full cost in writing before you start.
Bring the list of what you have tried
However long it is, Dr Nabavi will go through it with you and tell you whether Deep TMS, genetic testing or something else is the sensible next step.