Dr Ted Cassidy with a patient TMS Australia

Treatment options for severe depression

The treatment for depression is usually determined based on the severity of the symptoms, how much they impact day-to-day life and the previous treatments the person has received. Treatment-resistant depression occurs when a person does not respond to treatment; it is common for people to try more than one treatment.

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) recommend:

  • Medication as the first treatment for patients with severe depression
  • Repetitive TMS (rTMS)as a treatment option for severe depression if medication has failed or is not tolerated
  • Electroconvulsive (ECT) therapy be administered if needed for severe depression after other treatments have failed.

In some people the depression may be so severe that admission to hospital is required. Psychological therapy can be used at any stage and is often effective in severely depressed people when combined with another form of treatment.

The RANZCP guidelines recommend a step-wise approach to treating depression.

Step 1

  • Stop taking any substances that can affect mood
  • Introduce lifestyle changes such as improving sleep routine, quitting smoking, increasing exercise and eating a healthy diet

Step 2

  • Psychosocial interventions (e.g. education, support groups)
  • Psychological therapy
  • Medication

Step 3

  • Combine medication with psychological therapy if not done already
  • Increase the dose of medication and/or add a new medication
  • TMS

Step 4

  • ECT

What are the main treatment options for people with severe depression?

Depression medication

The mode of action differs for each antidepressant and the choice of antidepressant is based on the severity of the symptoms as well as side effects, cost, suicide risk and the clinicians experience.

There are many different types of antidepressants available and they are classed into groups according to their mode of action. Antidepressants with stronger side effects may be a severe depression treatment. These include medications from the SNRI (e.g. desvenlafaxine, venlafaxine, duloxetine and milnacipran) or TCA (e.g. amitriptyline, clomipramine, dothiepin, imipramine, nortriptyline, trimipramine and doxepin) classes.

If an antidepressant is not effective, the clinician may decide to adjust the dose of the medication or add an agent such as lithium to try to make it work better. They may also combine it with different antidepressants as certain combinations can be effective.

Transcranial magnetic stimulation (TMS)

TMS has been used as a severe depression treatment and most of the research into this treatment involve patients who have failed 2 or more previous treatments. There is strong evidence to show that TMS is effective in people with severe depression as well as those who have not responded to previous therapies. One study found that 58% of patients with depression who had been inadequately treated with an average of 3 different antidepressants responded to TMS treatment, and that 37% of patients entered remission.

Electroconvulsive therapy (ECT)

ECT is an effective severe depression treatment with more than 70% of people responding. It is an invasive procedure and can result in short-term memory loss. It is therefore used to treat severe forms of depression, particularly when a patient refuses to eat or drink, is at risk of committing suicide, has high levels of distress or has psychotic depression.

How do the treatments compare to each other?

In patients who have failed several treatments, TMS appears to be a more effective treatment option than another antidepressant, although there are no studies that directly compare this. ECT is also an effective option for patients with severe depression, with TMS being as effective or slightly less effective. TMS has the advantage that it is non-invasive and without major side effects.

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References

  • Black Dog Institute. Electroconvulsive therapy.
  • Carpenter L et al. Transcranial magnetic stimulation (TMS) for major depression: a multisite, naturalistic, observations study of acute treatment outcomes in clinical practice. Depression and Anxiety 2012; 29: 587-596.
  • Fitzgerald PB et al. A study of the pattern of response to rTMS treatment in depression. Depression and Anxiety 2016; 33: 746-753.
  • Malhi GS et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Aust New Zealand J Psych 2015; 49: 1-185.

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