Chronically Depressed? What to Do When Antidepressants Don't Work

The range of options includes cognitive behavioral therapy and brain stimulation techniques like ECT.

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It's important to find a well-trained cognitive behavioral therapist. A 2005 study by DeRubeis and Hollon compared 16 weeks of drugs, CBT, and a placebo and found a response rate of 58 percent in both the drug and CBT groups—but also that the level of therapist expertise might affect CBT's success rate. How best to find a practitioner? Start by inquiring at a nearby academic medical center or by searching the Academy of Cognitive Therapy's website. And give it two to five sessions before doing a gut check, says Hollon.

The Kansas student, who has battled depression—the dominant feature of her bipolar disorder—since childhood, had been in therapy and on a range of drugs before inquiring about ECT. As is typical, she started out with several ECT sessions per week. She tapered down to about one per month and ended treatments in June after about six months. She has felt well enough to be back in class, hold down an internship, and glean joy from darkroom photography and time with friends.

Short-term memory loss is the main concern with ECT, and it's not uncommon. The effect usually wears off after treatment ends, but some information may never return—that graduation ceremony you attended between sessions, for example. The student recalls struggling to remember a relative's name and still has to make lists for the grocery store and to rely on a daily planner, though she needed neither before ECT.

Some patients claim to have experienced far longer-lasting problems, which may be a consequence, say, of receiving more current than was necessary. ECT has changed significantly as understanding has grown about how to minimize memory side effects, says Rudorfer. He says that it "has much lower risk than decades ago—though the risk is not zero." Technique matters, including an ability to reach just the amount of electrical current needed to induce seizures, which can differ among patients; the placement of the electrodes on the head; and the type of stimulation used (brief or ultrabrief pulse causes the fewest cognitive deficits; an older type, sine wave stimulation, significantly more). Cognitive problems are considerably less pronounced when the electrodes are put on one side of the head instead of both, but the one-sided approach is not as effective in some people. Critics of ECT have insisted that it causes brain injury, but studies in humans and animals have not corroborated the claim, says Rudorfer.

Another caveat: The benefits don't necessarily last. One study showed that 84 percent of patients had relapsed six months after the treatments ended without any "maintenance therapy" (drugs—which may help after ECT even if they failed before—or less frequent ECT sessions). Still, other research has shown that after a successful course of ECT with some form of maintenance therapy, about 46 percent of patients remained well six months out. The college student now tries to manage her recurring depression with a combination of therapy, medication, and lifestyle changes—more exercise and sleep, light exposure, and taking fish-oil supplements—that she learned about from The Depression Cure: The 6-Step Program to Beat Depression Without Drugs, a book by her psychology professor at Kansas, Stephen Ilardi. "It might be attributable to other things, but I really feel like some of these [lifestyle changes] have been helping," she says.

[Read more about how lifestyle changes might help when you're depressed.]

Moving. Indeed, a growing body of research suggests that regular exercise, at least, might be a smart prescription to try—or to add to drugs or therapy. It appears to promote a good, stable mood by reinforcing self-confidence and a sense of control over one's health, says Andrea Dunn, a Colorado behavioral science researcher and a principal investigator for a pilot study exploring the impact of regular exercise on depressed adolescents. A possible mechanism: Exercise creates new neurons, she says, bolstering connectivity in the depressed brain, which often operates with a deficit of connections.