“Treatment-resistant” describes the treatment, not the patient.
When two or more adequate antidepressant trials have failed, the first question is not which drug to try next. It is whether the diagnosis was right: whether this is bipolar depression being treated as unipolar, a depression kept going by alcohol or sleep apnea or a thyroid, a personality or life-story problem that medication was never going to touch, or an illness that has simply not yet been treated adequately, at full dose, for long enough. Only after that review does the next-step pharmacology mean anything.
When the diagnosis holds, we treat resistant depression as the serious illness it is, with the full range of what psychiatry has: switching and combining antidepressants with a rationale, augmentation with lithium, thyroid hormone or an atypical antipsychotic, the older medicines most practices no longer use (tricyclics and MAOIs), and pharmacogenomic testing when metabolism is the likely reason a drug has failed. For patients who need TMS, esketamine or ECT, we make the referral and stay involved.
A 60-minute evaluation by video, or 90 minutes when the diagnosis itself is in question (a comprehensive evaluation or second opinion), with records reviewed in advance. We build a complete treatment history, every drug, dose, duration and result, and look hard for what has been missed: bipolarity, substance use, medical illness, sleep, and the circumstances of your life. You leave with a diagnosis you can trust, a sequenced plan with each step’s timeline, and a clear statement of whether TMS or another advanced treatment belongs in it.
Cost and insurance. Covered by the plans we accept; self-pay rates are on our insurance page.
A therapeutic dose, taken as prescribed, for long enough to judge, usually six to eight weeks at that dose. Many “failed” trials never reached either, which is one of the first things we check.
Yes, when they are the right choice. They are effective medicines that most practices no longer prescribe; we use them with the monitoring and dietary guidance they require.
When the evaluation supports it, yes, and we stay involved in your care through the course. We will also tell you plainly when we think it is not the next step.