If you’ve never heard of treatment-resistant depression, you’re not alone. Despite impacting around a million Canadians, treatment-resistant depression – classified as depression that doesn’t respond to two or more trials of antidepressant medication – is still rarely talked about outside of medical communities. And that’s an issue.
“Untreated depression doesn’t typically get better on its own,” says Dr. Carlos Lalonde, a Psychiatrist, and President and Chief of Staff at Homewood Health Centre. “If somebody has a mild to moderate form that goes untreated, it’s more likely to progress to a severe form of depression and more likely to progress to something like treatment-resistant depression.”
This can have a big impact on an individual’s overall health and quality of life, affecting their work, families and relationships. But that’s not the only risk, Lalonde says. “The ultimate risk, of course, is the setting in of that hopeless feeling and suicidal thoughts and potentially death from a very severe illness if it goes untreated.”
With rates of depression higher since the COVID-19 pandemic, there is even more cause for concern, because the proportion of people with treatment-resistant depression remains consistent. “If you take a third of the 3 to 4 million Canadians that are suffering with depression, you’re looking at about a million Canadians that meet criteria for treatment-resistant depression,” Lalonde says.
While it’s hard to predict exactly what causes treatment-resistant depression, experts have some idea of who may be more at risk of experiencing it.
“One of the biggest risk factors is having a more severe form of depression and another is experiencing a longer duration of depression,” Lalonde says. In addition to this, individuals who experience other disorders, such as generalized anxiety disorder, psychotic or delusional symptoms, substance use disorder or personality disorder, may also have a higher likelihood of experiencing treatment-resistant depression.
“The higher the complexity and the higher the number of concurrent disorders, the more likely that an individual may have some treatment-resistance,” Lalonde explains.
For many, addressing the challenge of treatment-resistant depression can be difficult and can vary greatly, depending on where a patient first enters the treatment chain. For example, if a patient is having suicidal thoughts, they may go to their local emergency room, be admitted to an inpatient psychiatry unit at the hospital or transferred to a facility like Homewood Health Centre, where their treatment would start.
Innovative options for treatment-resistant depression
“The question sometimes is: What treatments are available and where are they available?” says Dr. Sherief EL-Gaaly, Chief of Interventional Psychiatry Services at Homewood Health Centre. “And many of the interventional psychiatry services are not available in all hospitals.”
That’s where facilities like Homewood Health Centre come in. Celebrating its 140th anniversary this year, the organization provides specialized treatment for Canadians living with treatment-resistant depression, offering innovative interventional psychiatry services out of their Guelph, Ont. location.
These services utilize research-backed Electroconvulsive Therapy (ECT), repetitive transcranial magnetic stimulation (rTMS) and ketamine. Homewood Health Centre leverages its unique expertise in all three types of treatments under one roof, where many facilities may only specialize in one or two. Homewood physicians can work together with the patient to determine the best care approach with all the tools at their disposal. This is particularly important because patients may need one or more of these treatments, depending on what has worked in the past and how they respond over time.
EL-Gaaly explains that while studies of the three treatments have found ECT to be the most effective, it’s not always the best fit for a patient, because these treatments aren’t one-size-fits-all. This is yet another reason why it’s important to consider what is the ideal treatment option for each individual, based on the specifics of each case.
These treatment options are particularly exciting because the results can take effect very quickly once treatment starts. “Some of these treatments have a very rapid antidepressant and anti-suicidal effect,” EL-Gaaly says. For example, ketamine can result in a response within the first 24 hours. “For patients who have been suffering for very, very long, that is extremely important,” he says.
Homewood offers both in patient and recently launched out patient access to these services, for those who may not wish to stay in a treatment centre or who do not require an inpatient admission for their treatment.
“We’re hoping that by making Interventional Psychiatry Services available for both in patients and out patients, that we will be able to offer these treatments to as many people as possible,” EL-Gaaly says. “That when a depressed patient is feeling desperate and not responding to other treatments, they can have access to that.”
And, unlike treatment centres that do not offer access to all of these innovative treatments within an integrated service, facilities like Homewood Health Centre ensure that if one treatment doesn’t work for a patient, they don’t have to go back to the drawing board.
“We tell patients, we will work with you every step of the way to ensure that you have the highest possibility and likelihood of experiencing improvement in your depression with our service,” EL-Gaaly says.
Around 70 to 80 per cent of patients with treatment-resistant depression will have some response to these treatments. And while full remission is the goal, even some improvement can instill hope and be the jumpstart people – whose depression has caused a lack of energy, appetite, concentration, and sleep – need.
“Unfortunately, a higher number of people are suffering from depression, more people have treatment-resistant depression and there’s more people feeling hopeless out there,” Lalonde says. “There needs to be awareness of these other options – and accessibility to them.”