Happiness and sadness are the feelings that give colour to our emotional life. It is normal to feel happy when you receive good news, and to feel sad when you have lost someone you loved. However, when sadness becomes the predominant feeling in your life, you should wonder if it has become depression. Patients with clinical depression feel sad for weeks or months, not just a few days. There is a general lack of energy, it is hard to wake up in the morning and difficult to sleep at night. The loss of appetite and sex drive are also usually part of the picture.
Over time, the initial reason for the person to feel sad becomes less important, more of a catalyst rather than the real motive. Patients lose interest in things they used to enjoy, they look at the future with no positive expectations and sleep becomes a problem. People around you think it should be mind over matter, but who wants to be depressed?
You feel more isolated by those comments, and tend to withdraw from friends and family more and more. Unhappiness and helplessness have settled in. In some cases, depression is accompanied by symptoms of anxiety such us: restlessness, a sense of dread, feeling constantly "on edge", difficulty concentrating and irritability. There is a wide spectrum of depression that ranges from mild to severe forms, which include suicidal ideation or suicidal attempts.
In order to find the most appropriate treatment for clinical depression, you have to undergo a comprehensive mental health assessment with a consultant psychiatrist. During the assessment you will be asked about your personal and family history of anxiety and depression, the age of onset, previous treatments, relapses and also about your physical health history. Blood tests and psychological evaluation may also be needed to clarify the nature of depression. Once the comprehensive assessment has been completed, we will be in a position to discuss the best treatment option for your personal circumstances.
The OAD Clinic offers bespoke treatments for treating Depression.
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What is Treatment Resistant Depression (TRD)?
Major Depressive Disorder (MDD) is a mental disorder associated with persistent and pervasive low mood and sadness, low self-esteem, loss of interest or pleasure in normal activities (anhedonia), and a bleak vision of the future. Suicidal attempts are a frequent symptom associated with MDD. Treatment Resistant Depression is a debilitating subtype of MDD. People who have failed to respond to at least two different oral anti-depressants of an adequate dose and duration during their current depressive episode are regarded as having TRD.
Depressive patients also have difficulties with sleep, low appetite, diminished sexual drive, a general recurrent sense of lack of energy and enthusiasm (lethargy), and poor general health. Major depression has a massive impact on people’s personal and social life, it is a highly prevalent and disabling disorder.
What are the available therapeutic strategies for Treatment Resistant Depression?
There are many different strategic approaches for treating TRD. The vast number of treatments just mean that there is not a highly effective single one. The traditional approach to treating TRD has been a combination of high doses of different antidepressants under the supervision of an experienced clinician. Some patients are prescribed even more medications on top to manage the side effects of antidepressants. Even when patients manage to recover, they usually suffer from cognitive (memory, attention) disorder associated with the large number of medications prescribed. Some clinicians are inclined to combine antidepressants with stimulants (methylphenidate, amphetamines) but the associated physical and mental risks are very high. This approach is not very safe.
Some patients respond to combined hormone therapy and high dose of antidepressants, but that is usually the case when there is an underlying hormone (thyroxine, oestrogen) imbalance. Intense psychotherapy (frequent long sessions) have also been tried, but today we know that TRD is mainly a biological disorder related to chemical imbalances in the frontal lobe. Having said that, individual and family psychotherapy are a very important part of treatment but usually fail when they are not associated with pharmacological interventions
Electroconvulsive Therapy (ECT) is also an option for patients who have tried everything and failed every time. It has been used for more than 80 years, and it is mainly indicated for severe resistant depression or psychotic depression. One of the most recent pharmacological strategies for TRD is esketamine, available as nasal spray.
Esketamine is an NMDA receptor antagonist (different from SSRIs or MAOIs), that contributes to the restoration of synaptic function in dopaminergic brain regions involved in the regulation of mood and emotional behaviour. It is useful for increasing motivation and anhedonia. Esketamine treatment usually produces a quicker mood improvement when compared with other antidepressants. It also involves a more complex procedure and follow up.
Spravato is a medicine that contains esketamine and is licenced in the UK for the treatment of TRD. It is taken by a nasal spray device.