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Psychiatry: Treatment Resistant Depression Clinic

Treatment-resistant depression, or refractory depression, refers to a major depressive disorder that does not respond to adequate courses of at least two different antidepressants.

Charles R. Conway, MD, associate professor of psychiatry, is working with other clinicians and researchers on alternative therapies for these patients. The newly formed Treatment-Resistant Depression Clinic at Washington University is wholly dedicated to helping these patients find a better quality of life.

According to Dr. Conway, people with treatment-resistant depression (TRD) have very difficult lives. It’s an incapacitating disease with a high suicide risk. I t is estimated that about 5% of people with depression have severe TRD.

The first course of treatment for depression is always medication. Often it takes a combination of two or more different medications to control symptoms, and it takes time to find the right combination for each patient. Patients must also take their medications as described. When medicine has been tried and doesn’t work, patients can be referred by their physicians to the TRD Clinic.

Appointments can be scheduled by calling 314-286-1700. A physician referral is needed.

Yvette Sheline, MD, professor of psychiatry, advises that there are a nDrs. Svrakic, Conway and Shelineumber of options today for patients for whom medication is ineffective.

After review of the records, and complete medical examination of the patient, the treatment team may recommend vagus nerve stimulation (VNS), transmagnetic stimulation (rTMS), electroconvulsive therapy (ECT), or additional medications, perhaps a supplement to what the patient is already taking. Sheline states, "We work closely with the referring psychiatrist, who will continue to manage the patient on an on-going basis.”

Sheline, Conway, and Dragan M. Svrakic, MD, PhD , pictured above (right to left), make up the TRD Clinic team who evaluate and treat patients, should they need any of the treatments described. They also are involved in several clinical studies that are available to patients who qualify.

One of the treatments showing great promise is Vagus Nerve Stimulation (VNS). VNS was first approved for the treatment of refractive epilepsy 15 years ago. In 2005, the FDA approved it for treating TRD. Even though it is approved, most insurance still doesn’t cover it. While VNS is expensive, so are years of failed medical therapy.

VNS can be compared to a pacemaker—but for the brain. The device is implanted under the skin below the collarbone. A lead is tunneled under the collarbone, where it is surgically implanted onto the vagus nerve on the left side of the neck. The impulse generator regulates the electrical stimulation going to the vagus nerve.

Unlike many of the existing treatments for depression, the effects of VNS tend to be very slow to start, but can be profound. Dr. Conway states, “I believe this to be the best treatment for TRD; the effects tend to last. The implant is designed to be permanent, and in our experience only 5% of patients opt to have it removed.

About one-third of patients have a dramatic reduction in their depressive symptoms. They basically go into remission and are often able to significantly reduce the amount of medication they take. Another third of treated patients have a significant improvement in their quality of their life and are happy about having the device.” The device has different settings which can be adjusted through the skin electronically. Studies are in progress to determine the optimal settings for depression.

Electroconvulsive Therapy (ECT) is still the gold standard for getting patients better. Washington University is a leader in ECT, which has changed greatly over the years. For patients who had it before and did not respond, Sheline asks: Did they have enough treatments? Were they strong enough? Were they done to both sides of the brain? All of those parameters have been found over the years to be significant for effective ECT. The down side of this therapy is that the effects don’t tend to last in those suffering from TRD and treatment must be repeated periodically. Long-standing ECT, or “maintenance ECT”, can be one way around this limitation.

Transmagnetic Stimulation (rTMS): Says Conway, “Most clinicians think of it as a treatment for non-resistant depression, for those who are mildly to moderately ill. Its niche is people who don’t want ECT, and pregnant women who want to avoid taking psychotropic drugs during their pregnancies. A magnet is placed on the scalp and aimed at a particular spot in the brain. Treatments must be given 5 times a week for several weeks before patients’ symptoms improve. Because it is the newest in regard to FDA approval, there is very little long-term data available.”

Because so little is known about treatment resistant depression, the Clinic will also be tracking patient’s responses to various treatments. Some current studies using neuroimaging-functional MRI and PET) will help predetemine the best treatment choice for each patient, thereby shortening the time from evaluation to effective relief of depressive symptoms.

The message, says Sheline is this: “Don’t give up. There is hope. We have so many more options than we did in the past for treating this devastating disease.”

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Copyright 2015 Washington University School of Medicine
Copyright 2015 Washington University School of Medicine