Treatment-Resistant Depression: When Antidepressants Have Not Been Enough

Maybe this sounds familiar. You have done what was asked of you. You took the tablets, went back to the doctor, tried a second medication and perhaps a third. Some of the sharpness has gone, but the heavy grey cloud is still there when you wake, and getting through an ordinary Tuesday takes everything you have.

If that is where you are, please hear this first: you have not failed at getting better. Depression that is slow to lift is common, and it says nothing about your effort or your character.

What "treatment-resistant" means

Doctors generally use the term treatment-resistant depression when someone has tried more than one antidepressant, at a proper dose and for long enough, without enough improvement. It is an unkind-sounding phrase for something quite ordinary. It does not mean nothing will help. It means the first options have not been enough on their own, and that it is time to look more widely with your doctor or psychiatrist.

Depression itself is far more than sadness. It can show up as:

A flatness where pleasure and interest used to be
Exhaustion that sleep does not repair
Slowed thinking, poor concentration and difficulty making small decisions
Changes in appetite and sleep
Withdrawing from people, even those you love
Harsh, guilty thoughts about yourself

If you ever have thoughts of harming yourself or of not wanting to be here, please contact your doctor or the South African Depression and Anxiety Group (SADAG) straight away.

The frontal lobes, alpha and motivation

The front part of the brain, just behind the forehead, is thought to play a large role in mood and motivation. Some research suggests that the left and right sides may do slightly different jobs. Left frontal activity has been linked with what researchers call approach: interest, drive, moving towards things. Right frontal activity has been linked more with withdrawal and caution.

Brain cells produce rhythmic electrical activity known as brainwaves. One of these rhythms, alpha, is a slower wave that is thought to appear when an area of the brain is idling. A lot of alpha over one region is usually read as a sign that the region is less active at that moment.

In some people with depression, brain recordings have shown more alpha over the left frontal area than the right. This is known as frontal alpha asymmetry. One interpretation is that the side of the brain associated with drive and interest may be idling, while the side associated with pulling back is doing more of the work.

It is important to be honest about this. The pattern is not found in everyone with depression, studies have not all agreed, and it cannot be used to diagnose anyone. Depression has many contributors, including life events, physical health, hormones, sleep and loss. What the idea does offer is one way of seeing that the heaviness may have a physical side.

Depression is not a lack of willpower, and it is not a flaw in your character.

Where neurofeedback fits

Neurofeedback is a non-invasive form of brain training. Sensors on the scalp read your brain's electrical activity, and a computer gives feedback through sound or images whenever the brain moves towards the pattern being encouraged. The sensors only read. Nothing is sent into your brain, and it is not a medication.

For low mood, one approach that has been studied aims to encourage a more even balance of activity between the left and right frontal areas. The hope is to support mood, energy and clearer thinking. The evidence for neurofeedback in depression is limited and still developing, results vary a good deal, and it would be wrong to promise that it will lift a depression.

Neurofeedback works alongside your doctor, psychologist or psychiatrist, never instead of them. Please do not stop or reduce an antidepressant without the doctor who prescribed it, even if you start to feel better. Stopping suddenly can make you feel very unwell and can bring the depression back. If you are considering neurofeedback, tell your treating doctor.

Long-term low mood often travels with other things. If yours came after years of pushing too hard, you may recognise something in our article on emotional numbness and burnout. If sleep is broken, restoring sleep may be a sensible place to begin.

What to expect at our practice

Every client starts with a 19-channel brain map at our practice in Krugersdorp, which takes about an hour and a half. A brain map is a recording of your brain's electrical activity, taken from 19 points on the scalp.

Training sessions take 45 to 60 minutes and begin with a short check-in on how you are feeling. After that, the sensors read your brain's activity while you sit. Our what to expect page explains the process in more detail. For a gentler read on holding on through hard seasons, you might also like hope as an antidote.

Common questions

Can I stop my antidepressants once I start neurofeedback?

No. Please do not stop or reduce an antidepressant on your own. Any change to medication must be made with the doctor or psychiatrist who prescribed it, usually slowly and under supervision. Neurofeedback is a complementary approach that works alongside your medical treatment, not as a replacement for it.

Does neurofeedback cure depression?

No one can honestly promise that. Neurofeedback is brain training that may help some people with mood, energy and sleep, but the evidence for depression is still limited. Results vary from person to person. It is best seen as one support among several, together with medical care, therapy with a psychologist, movement, sleep and the people around you.

Is neurofeedback the same as shock treatment?

Not at all. Neurofeedback puts nothing into your brain. The sensors resting on your scalp only read your brain's own electrical activity, much as a thermometer reads temperature. The computer then gives you feedback through sound or pictures. There is no current and no anaesthetic.

Depression that has stayed too long can make it hard to believe anything will shift. You do not have to believe it today. If you would like to talk about whether neurofeedback could sit beside the care you already have, you are welcome to contact Irine whenever you feel ready.