Treatment Resistant Conditions

What it is: Depression that hasn’t lifted after two good antidepressant trials (usually from different classes) and a solid try at therapy.

How we move forward:

• Fine-tune meds (adjust dose, switch, or add a helper like bupropion, mirtazapine, lithium, or others when appropriate).
• Try a different therapy fit (CBT, behavioral activation, IPT).
• Consider neuromodulation like TMS/Deep TMS (noninvasive). For severe or urgent cases, ECT may be recommended. Esketamine/ketamine may be options for select patients.
• Support the whole person: sleep, exercise, routines, pain, hormones, and nutrition.

What it is: Anxiety that keeps getting in the way despite an SSRI/SNRI trial and a real course of CBT with exposure.

How we move forward:

• Optimize or adjust medication (including buspirone or pregabalin where appropriate).
• Dial in exposure-based CBT (reduce safety behaviors, practice skills between sessions), or try ACT/metacognitive therapy.
• Explore neuromodulation (TMS protocols are emerging for some anxiety conditions).
• Tackle drivers like insomnia, caffeine/nicotine, and thyroid issues.

What it is: PTSD symptoms that persist after trauma-focused therapy (like Prolonged Exposure, CPT, or EMDR) and at least one medication trial.

How we move forward:

• Switch or intensify trauma therapy (including massed sessions).
• Refine medications (optimize SSRI/SNRI; prazosin can help with trauma-related nightmares).
• Consider advanced options (TMS has growing evidence for PTSD; ketamine-assisted care may be available in specialized settings).
• Strengthen foundations: sleep treatment, pain care, substance use support, and work around moral injury.