Treatment-Resistant Depression (TRD) remains a significant issue for many people and TRD research on a large population can help build scientific understanding that can lead to more effective treatment. A recent study by Lundberg, et al., aimed to examine the impacts of TRD, on both individuals and society, and to find out if there is a way to predict that a person who is beginning to suffer an episode of Major Depressive Order (MDD) will eventually be considered to have TRD. The purpose of this prediction would be to reduce that amount of time that patients spend in trying a treatment that is not working before switching to a different treatment.
Defining TRD
This study defined Treatment-Resistant Depression generally as an MDD episode that has not responded to trials of two different antidepressant classes over about 4-6 weeks. However, for the purposes of the study, the authors considered TRD to require “3 or more treatment trials (AD [Anatomical Therapeutic Chemical code N06A antidepressants], add-on medication [aripiprazole, lithium, olanzapine, quetiapine (>100 mg), risperidone], ECT, or repetitive transcranial magnetic stimulation).”
The Study’s Methodology
The Lundberg study is particularly significant for its size. The participants, drawn from a larger group called the Stockholm MDD Cohort, were selected among all those listed as having an MDD episode during a five year period in the Stockholm region. The sample was narrowed down to only include unipolar MDD episodes of people who had lived in Stockholm for more than a year preceding the episode. There was also a secondary sample for the purposes of trying to create a TRD prediction algorithm, which was selected from a two-year period’s MDD episodes, of patients who had resided in the Stockholm region for 3 years or more before the episode.
This selection ultimately resulted in a study population of 158,169 unipolar MDD episodes, of which 12,793 met the study’s criteria for TRD. These TRD episodes were combined with 62,817 non-TRD episodes, for a primary sample of 75,610 episodes.
This was an observational study, using anonymized patient data, for which the authors conducted analysis over a nearly two-year period.
Important Findings of This TRD Research Study
Lundberg et al. found in their TRD research that the patients who experienced TRD were more likely to struggle with issues such as sleep disorders, substance abuse, and self-harm, as well as missing more days of work, compared to patients who had MDD but not TRD. The all-cause mortality rate for TRD patients was also higher than for MDD patients without TRD. With regard to predicting that a patient will experience TRD, the authors found that the severity of depressive symptoms at the time of diagnosis is a “strong prognostic factor for TRD.”
In addition to the heightened risk of all of these issues, patients in MDD episodes who would eventually meet the qualifications for TRD are suffering without adequate relief for their depressive symptoms. The authors found that the median time in between the start of the first treatment trial and the start of the second was 165 days, or over five months. From the start of the second treatment trial and the start of the third was 197 days, or over six months. This is significant because it means that patients are being kept for longer than necessary on an antidepressant that is not working for them, before having the opportunity to try a different medication. The authors of this TRD research study alluded to other research on this subject, noting that, “This long duration is contrasted by the findings that nonresponse can be reliably predicted 2 weeks after initiating an [antidepressant] and that median time to remission in clinical trials typically is 8 weeks or less.”
The authors also discussed that when the initial treatment with an antidepressant in the Selective Serotonin Reuptake Inhibitor (SSRI) class failed, providers tended to prescribe another SSRI or a different monoamine reuptake inhibitor, rather than a different approach such as adding lithium or an atypical antipsychotic to the primary antidepressant to augment its effects.
The authors also noted that repetitive Transcranial Magnetic Stimulation (rTMS,) is underutilized for the treatment of TRD, while also citing another study that found rTMS effective in the treatment of TRD. This, coupled with the study’s information about how patients are being kept on antidepressants that are not working longer than necessary, and sometimes on only one class of antidepressants, underscores the importance of providers considering other treatment methods, particularly TMS.
If you are suffering from Treatment-Resistant Depression, Contact Mid City TMS
At Mid City TMS, we focus on helping patients with Treatment-Resistant Depression to find effective relief. With many years of experience treating patients with TRD, Dr. Bruno has successfully used methods including antidepressant medications and TMS to provide relief beyond what patients thought possible. Contact us to learn how Mid City TMS can help you.
