While medication in conjunction with therapy is the most common treatment for Major Depressive Disorder (MDD), there are additional depression treatment options which are particularly useful when a patient hasn't achieved remission of depression symptoms after many medication trials.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) involves the induction of seizures through electrical stimulation of the brain in an anesthetized patient. Electroconvulsive therapy is still considered controversial by some researchers, but in studies ECT has shown a better response rate than medication in cases of depression.

Electroconvulsive therapy varies depending on the placement of electrodes, frequency of treatments, number of treatments and electrical waveform used during stimulation. Some combinations are thought to be more effective although other combinations may have fewer side effects. Electroconvulsive therapy can be given as an in-patient or out-patient procedure.

Pros: High likelihood of response compared to medication; response may be much faster than to an antidepressant.

Cons: May result in cognitive deficits such as short-term memory loss; may also require time off work. Electroconvulsive therapy tends to be effective only short-term.

More on Electroconvulsive therapy (ECT)

Vagus Nerve Stimulation

Vagus nerve stimulation (VNS) uses an implanted device to electrically stimulate the left vagus nerve. The device is implanted in the chest and wires, or leads, transmit the impulse across the chest and up to the vagus nerve. The vagus nerve is stimulated for a number of seconds at a set interval, such as every 30 minutes. VNS therapy is added to medication treatment in cases of hard to treat depression.

Once the VNS device is implanted it must be turned on and checked on a regular basis by a doctor certified by the device manufacturer.

Pros: Treatment specifically shown to work in cases of hard to treat depression; no additional medication side effects.

Cons: Cost and availability of treatment as well as possible physical side effects from the device or from surgery.

More on Vagus Nerve Stimulation (VNS)

Repetitive Transcranial Magnetic Stimulation

Repetitive transcranial magnetic stimulation (rTMS) is the repeated application of weak electrical currents to parts of the brain using a pulsed magnetic field. In treatment the patient has a plastic-encased metal coil placed on their scalp to allow for targeting of the magnetic field. In some cases rTMS is thought to be as effective as ECT although some still consider this a controversial treatment.

Pros: Not associated with the memory loss of ECT.

Cons: Cost, availability and possible physical side effects during treatment such as headaches, or seizure.

More on Transcranial Magnetic Stimulation (TMS Therapy)

Therapy is recommended for all mental health issues, but may be particularly helpful in the treatment of MDD (major depression disorder). Therapy types include:

• Cognitive behavioral therapy: addresses thoughts feelings and behaviors that affect your mood. It attempts to alter negative thinking patterns. One benefit is this type of therapy is often short-term, around 12 sessions.
• Dialectical behavioral therapy: an intensive therapy that focuses on mindfulness, interpersonal effectiveness, emotion regulation and distress tolerance skills.
• Interpersonal / Family therapy: addresses individual issues and those of the family, particularly focused on relationships and working out stress.
• Group psychotherapy / Support groups: a group of people each with MDD or a related disorder supporting each other through their illnesses. Support groups are normally made up of peers while group psychotherapy includes a professional psychotherapist.
• Psychodynamic treatment: sometimes known as talk therapy this is one-on-one treatment is designed to handle issues underlying depression. This type of therapy may take longer than others due to the type and depth of issues discussed.

Pro: Many benefits of psychotherapy for depression. Side effect free and may help all parts of life.

Con: Can be expensive and sometimes lengthy.

While the name antipsychotic suggests this medication is for the treatment of psychosis, this is not altogether the case. Antipsychotic medications are commonly prescribed for the symptoms of schizophrenia, such as delusions or hallucinations, but they are also prescribed for bipolar disorder and major depression.

Antipsychotics for Depression

Antipsychotics are broken down into two groups:

• Typical antipsychotics, also known as first generation antipsychotics
• Atypical antipsychotics, also known as second generation antipsychotics

Atypical antipsychotics are the type most commonly prescribed for depression. They may be prescribed alone or in addition to other medication. Commonly prescribed antipsychotics include:

• Seroquel
• Zyprexa
• Abilify
• Geodon
• Symbax (contains a combination of Zyprexa and Prozac)

Pro: Antipsychotics work on the brain differently than antidepressants and may help those who haven't been helped by antidepressants.

Con: Antipsychotics can have serious side effects such as weight gain, muscle ticks and blood sugar modification.

Mood Stabilizers For Treatment of Depression

Mood stabilizers are a class of medications most frequently used to treat bipolar disorder but can also be used in MDD particularly if there is suspicion of bipolar disorder. Mood stabilizers may be prescribed alone or, more commonly, prescribed with an antidepressant.

Mood stabilizers are medications that are known to treat either high or low moods or both. For example, a mood stabilizer may effectively treat depression while not treating mania, but not making the mania any worse.

Because the definition is based on effect rather than on how the drug works, many types of drugs can be thought of as mood stabilizers. Some anticonvulsants (seizure medication) and antipsychotics fall into this group. The most common mood stabilizers used for the treatment of depression include:

• Lithium
• Lamictal

Pro: These medications work differently than antidepressants or antipsychotics and lithium, specifically, has a long treatment history. May be particularly beneficial if bipolar depression is suspected.

Con: Less evidence is available for using these drugs to treat MDD.

Treating Depression with Other Medications and Supplements

Some people respond when specific supplements are added to their medication, and in rare instances, supplements alone. The two supplements supported by data are omega-3 and L-methylfolate. The herb, St. John's Wort, can also be used in the treatment of depression.

Pro: These options tend to have fewer side effects.

Con: Concentration and quality cannot be guaranteed for unregulated over-the-counter products. There is less evidence supporting the use of St John's Wort in the treatment of MDD. L-methylfolate is thought to help only a small percentage of people.

The Cytochrome P450 (CYP450) Genotyping Test

Least common is to take the cytochrome P450 (CYP450) genotyping test. This test attempts to predict which antidepressant is right for you by checking for genes that show how you metabolize types of medication. This and other gene tests aren't commonly available.

Hard-to-treat depression can result in hopelessness and thoughts that your depression won't go away. However, don't give up. Once standard antidepressant medication and depression therapy options have been tried, there are still many options for the treatment of major depression.

Single Medication Options for Major Depression Treatment

There are three main options when antidepressant medication isn't working:

1. Stay on the medication longer
2. Increase the medication dose
3. Change antidepressants and try a new antidepressant medication

Recommended antidepressant medication trial times are provided by the drug manufacturer; however, many doctors choose to switch medications before the recommended time as the time can be quite long. Taking the medication longer may increase the chances of it being effective.

Pro: The medication may start working.

Con: If the medication doesn't work, it delays trying a new treatment.

Increasing the dose is another common option. Medications work within a range of dosages and for many drugs their effectiveness increases with the dose. Your doctor may increase the dose to improve the possibility of a successful drug trial.

Pro: The medication may start working.

Con: There may be more side effects at a higher dose and if the higher dose isn't effective it delays trying a new treatment.

Switching antidepressants to a different type of antidepressant medication is also common. While all antidepressants work on the neurotransmitters (chemicals) in the brain, each one works in its own way and many on a unique subset of neurotransmitters. Just because two or three antidepressants don't work doesn't mean that none of them will. Common types of antidepressants include:

• Selective serotonin reuptake inhibitors (SSRI) such as Celexa and Prozac
• Serotonin-norepinephrine reuptake inhibitors (SNRI) such as Cymbalta and Pristiq
• Norepinephrine-dopamine reuptake inhibitors (NDRI) such as Welbutrin
• Noradrenergic and specific serotonergic (NaSSA) such as Remeron
• Serotonin antagonist reuptake inhibitors (SARI) such as Oleptro
• Tricyclic (TCA) such as Tofranil
• Monoamine oxidase inhibitor (MOAI) such as Parnate and Nardil
• Norepinephrine (noradrenaline) reuptake inhibitors (NRI) such as Strattera, an ADHD medication which is not FDA approved for depression.

Pro: New neurotransmitters are being targeted so response and side effects may be different.

Con: Some medications may have unwanted side effects.

Depression Medication Combinations

Some people respond to a combination of medications. This may be because of the additional neurotransmitter changes or because of the effect one medication has on the other. Many useful combinations are known. Most combinations include an antidepressant plus another type of medication although some people find a combination of antidepressants or a combination of non-antidepressants effective. A new National Institute of Mental Health study, COMED, is being undertaken to test the use of two different antidepressants at the same time to improve or quicken the effect.

Pro: By adding a medication more neurotransmitters can be targeted in unique ways. One medication may also improve the effectiveness of the other.

Con: Multiple medications can increase the number of side effects and may have undesirable interactions.

Antidepressants and Therapy for Treatment of Major Depression

A person with MDD is typically given an antidepressant medication as the first-line treatment for Major Depressive Disorder. The antidepressant is generally in the class known as selective serotonin reuptake inhibitors (SSRIs). These include antidepressants such as Lexapro and Prozac. This class tends to be the most effective with the fewest side effects for people with MDD. A doctor will select a specific SSRI based on the patient's symptoms, their history and the specific characteristics of the drug.

When a person is diagnosed with MDD, they are also generally advised to get depression therapy. Therapy in conjunction with antidepressant medication is more effective than either depression treatment alone.

The antidepressant is typically taken at the recommended dose for a recommended time to judge efficacy. (Recommendations come from the drug manufacturer as supplied to governmental agencies.) This period may be up to 12 or more weeks depending on the specific antidepressant medication. This is known as a medication trial. Once the end of the trial is reached, the doctor and patient assess whether the antidepressant medication is working and how well it is being tolerated. If the depression hasn't remitted, hasn't remitted enough, or the antidepressant side effects are unacceptable, a new medication trial is usually begun.

Some medication trials are ended early due to the physical or psychological needs of the patient, although these are not considered complete trials.

Deviations from the Standard Course of Treatment for Major Depressive Disorder

Some individual doctors or patients deviate from the standard treatment of MDD for non-medical reasons. This may be because:

• The patient requests a change
• The patient requests a specific drug
• Free patient samples are available of a specific drug
• The doctor prefers a different course of treatment

It is important to note that deviating from the standard course of treatment for Major Depressive Disorder, particularly by the patient insisting on a specific drug, may be a reason why remission from depression is not achieved.

In order to evaluate whether you fall into the category of hard to treat depression, consider these questions:

1. I have been diagnosed with major depressive disorder.
2. I have not been diagnosed with any other illness.
3. I have had a blood test to screen for deficiencies or abnormalities in vitamin, mineral and hormone levels.
4. I take my medication exactly as prescribed.
5. I have tried at least two antidepressants at a therapeutic dose for the prescribed amount of time.
6. I have had 16 weeks of therapy for depression.
7. I have applied what I learned in therapy in my daily life and my mood has not improved.
8. I experience no relief from my symptoms of depression.
9. I experience some relief but am still depressed and "not myself".
10. My symptoms of depression remit but then later return.

If you've answered 7 - 10 of these questions "yes" you likely fall into the category of hard to treat depression.

While no one knows why some people react positively to antidepressant treatment and others don't, there are some factors that appear to play a part in causing hard to treat depression.

Stress

People in a stressful environment often will not find complete relief of depression symptoms from antidepressant medication alone. Stress causes changes to the brain's chemicals and affects how the brain works. (See" Relationship Between Anxiety and Depression.)

Examples of stressors include:

• A death in the family
• Relationship issues
• Financial problems
• A new job

Depression and anxiety therapy can help many people learn to deal with the stress in their lives and help remission become a reality.

Medication Non-Compliance

Medication non-compliance includes taking medications in any way other than prescribed.

Examples of this include:

• Skipping doses
• Taking more than prescribed
• Taking less than prescribed
• Taking the medication at a time other than prescribed (like taking the medication at bedtime rather than in the morning)

By not adhering to the dosage and schedule set out by the doctor, the medication may not have a chance to work or it may stop working. People may alter their medication schedule for a variety of reasons:

• Vacation
• Forgetting to take the medication
• Thinking they no longer need the medication

If the medication dose or schedule is changed for any reason, it's important to be honest with your doctor about it so your doctor can help get you back on track.

Other Health Problems

Other medical problems can worsen depression or even mimic its symptoms. It's important that all other health-related issues be ruled out if MDD treatment isn't working. Common problems that may cause depression-like symptoms or worsen depression include:

• Thyroid disorders
• Vitamin deficiencies
• Anemia
• Heart problems
• Substance abuse
• Chronic pain

Many of these issues can be ruled out by simple blood tests and once the underlying condition is addressed the issues of depression lessen or disappear completely.

Other Mental Illnesses

Depression commonly occurs alongside other mental illnesses like anxiety or borderline personality disorder. These other mental illnesses may require additional treatment or a change in the way the depression is treated.

For example, some antidepressants are known to have anxiety as a side effect, so these should not be given to someone who is already anxious.

Depressive symptoms also commonly mask some types of bipolar disorder. While individuals experiencing a full-blown manic episode are easy to diagnose with bipolar disorder, those with other types, such as bipolar depression, who are often misdiagnosed with MDD.

Soft Signs of Bipolar Disorder

The DSM-IV describes type I bipolar disorder as having depressive and manic symptoms and type II bipolar disorder as having depressive and hypomanic symptoms. Hypomanic symptoms are much less severe than manic symptoms and can be harder to detect.

Additionally, some doctors believe there are additional "soft signs" of bipolar disorder which in and of themselves do not indicate bipolar disorder, but put together can be suggestive of bipolar depression. Soft signs may also indicate that non-antidepressant treatments are more appropriate. Soft signs of bipolar include:

• Repeated episodes of major depression (four or more; seasonal shifts in mood are also common)
• First episode of major depression occurring before age 25
• A first-degree relative (mother/father, brother/sister, daughter/son) has a diagnosis of bipolar disorder
• When not depressed, mood and energy are a bit higher than average, all the time
• When depressed, symptoms are "atypical": extremely low energy and activity; excessive sleep (e.g. more than 10 hours a day); mood is highly reactive to the actions of others
• Episodes of major depression are brief, e.g. less than 3 months
• Psychosis (loss of contact with reality) during an episode of depression
• Severe depression after giving birth to a child
• Hypomania or mania while taking an antidepressant
• Loss of response to an antidepressant, i.e. it worked well for a while then the depression symptoms came back, usually within a few months
• Having tried three or more antidepressants without response

An experienced psychiatrist can differentiate the types of mental illnesses present, but it's important to be completely honest with the doctor about all symptoms so he can have all the facts on which is base his assessment.

Remission from depression is the goal of depression treatment, and perhaps more importantly, people who find a depression treatment that completely relieves their depression symptoms are less likely to have a depression relapse in the future.

A Doctor's View of Remission From Depression

Depression is a self-reported illness, meaning most depression symptoms are judged by the effected person. Based on the patient's responses to a series of questions, the doctor is able to assign the illness a score. They may or may not share this information with the patient. The patient is considered to be in remission from the illness when the score drops below a certain level.

A Patient's View of Remission From Depression

In practice though, remission is different for each person. It is generally considered to be a return to your "usual, normal self" - as you were before the illness. Patients note a variety of factors in this assessment, but of most importance is often:

• Optimism
• Self-confidence
• Return to a normal level of functioning
• A general sense of well-being
• Absence of symptoms of depression

Did you know that most people taking antidepressant medication for Major Depressive Disorder (MDD, severe depression) do not get completely better? In this article, we'll focus on:

1. What is hard to treat depression?
2. Causes of hard to treat depression and why some people don't completely recover after taking an antidepressant medication alone
3. Do you have hard to treat depression? Take our depression treatment screening test.
4. You've tried at least two different antidepressants and they've failed to completely relieve your depression symptoms. Learn about treatment for hard to treat depression.

Antidepressants and Therapy Aren't Working for My Severe Depression

What is hard to treat depression?

While MDD (major depression) is a highly treatable medical condition, it can take time to find the treatment that is right for you. Hard to treat depression is thought of as MDD which has not responded sufficiently to two or more antidepressant medication trials or therapy. This can mean there was no response to treatment or there was only partial treatment of symptoms. Depression also may be considered hard to treat if depressive symptoms keep reoccurring.

Note: hard to treat depression is not defined in the Diagnostic and Statistic Manual of Mental Disorders (DSM).

Antidepressant Treatment: How many people respond to treatment?

The rate of treatment response to first-line depression treatment with SSRIs is between 40% - 60%, but the rate of complete remission from depression is only 30% - 45%. This indicates that most people do not achieve complete remission from their first SSRI medication. Moreover, 10% - 30% of patients do not respond adequately to antidepressant treatment in general.

What Does Coming Out Gay Mean?

Coming out gay refers to the process of accepting one's own sexuality and embracing it, followed by disclosing it to family, friends and co-workers. Due to different amounts of social and family pressures that surround each individual, coming out gay is different in each instance. (Thinking about coming out gay? Read: What is Coming Out, and Should I Come Out of the Closet?)

To start with, coming out gay can often be confusing and scary because of:

• being fearful of other's reactions
• concerns for the person's own future
• concerns over scrutiny and discrimination

These concerns are all valid and represent a fear of the unknown. However, this time can also be seen as an opportunity for personal reflection; examing who the individual is and who the individual wants to be. Because of this, many people who have come out gay refer to it as a process of being reborn.

How to Come Out Gay

Create a personal inventory when coming out.

Although being gay does not define a person, it is nonetheless a new part of that person's life. The individual does not have to completely alter their personality, they are still who they are, but when  you come out gay, it does provide an opportunity to:

• reflect and evaluate your own life and transition
• concentrate on your own well-being and personal feelings
• educate yourself as much as you can about these issues
• create and plan a personal direction of your gay lifestyle

Coming Out Gay: Know that you are not alone.

Oftentimes when a person comes out gay, they feel isolated and different regardless of where they live and who they surround themselves with. These feelings are commonplace and felt by millions around the world at any given time. There are many gay support groups, organizations, resources and forums one can go to in order to deal with this stress. These include gay community centers and gay online communities, where one can find others dealing with similar issues who can offer some support.

Tell family and friends you're gay when you're ready.

Any person who has come out gay has dealt with a certain amount of stress in dealing with the reaction of his or her loved ones. Many are afraid that their family will reject them, or that their friends will no longer be comfortable with them, or their social standing might be jeopardized. These concerns are valid and must be dealt with at some point. Unfortunately, there is no way of predicting the reactions of family and friends. In the end, the overriding concern must be the individual's own health and well-being.

One must try to surround themselves with as many positive support structures as possible. If a person's family does not take kindly to the news, they should try to educate their family regarding their lifestyle and maybe seek out a support program at a local gay community center.

Coming out gay is not a race and there is certainly no set timeline one must adhere to. Each person's situation is different and demands a different pace. The one common theme that seems to be present amongst all individuals who come out gay is the liberation of no longer having to lie or hide the truth. Keeping these truths hidden away from oneself and others can have a negative impact with a person's psyche and mental health in the long run.

Other Helpful Coming Out Articles

• Coming Out at Work? Consider These Things
• Coming Out to Parents GLBT
• Teenagers Coming Out GLBT – The Four Stages
• Top 4 Ways You Shouldn't Come Out LGBT

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