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Treatment-resistant depression (TRD) is a severe form of Major Depressive Disorder (MDD) that does not fully respond to medications and/or evidence-based psychotherapy. Many patients with treatment resistant depression have been trialed on several anti-depressants, but continue to experience reduced quality of life due to persistent depressive symptoms. This experience of seeking relief through first line interventions, and continuing to struggle, can leave patients with TRD feeling frustrated and unsure what to try next.
At The Mind Grove TMS Center in Colorado Springs, we take a closer look at the full clinical picture to better understand the underlying explanation for cases of treatment resistance. Megan Bowers, MD, PhD personally evaluates your diagnosis, symptoms, treatment history, current medications, safety considerations, and the factors that may be getting in the way of your progress.
Recommendations may include a combination of TMS, changes to medication, augmentation strategies, or addressing a contributing concern that may be interfering with response to treatment.
It is estimated that 30-55% of adults and 20-40% of adolescents with Major Depressive Disorder meet criteria for treatment resistant depression, making this relatively common for patients with MDD. Although there is no consensus definition of treatment resistance, the most commonly used definition is failure to respond to two or more antidepressants despite taking medications daily, at an adequate dose, and for an adequate amount of time. Lack of response is also not well-defined, however most clinicians would consider the continued presence of moderate to severe symptoms that interfere with daily functioning as an indication that depression has not been adequately treated, and that an alternative medication or other intervention should be offered.
Lack of response to first-line treatments for MDD is not always due to treatment resistant depression. The presence of treatment resistance may be a sign that your diagnosis is incorrect, or that there are additional mental or physical health diagnoses impacting your treatment. At The Mind Grove, we take a comprehensive approach to treatment for TRD, starting with reconsidering the factors that may be impacting your progress.
Your evaluation may include discussion of:
The purpose of this in depth evaluation is to ensure the treatment recommendation is appropriate for your unique history and current goals.
Some of the most common contributors to a reduced response to antidepressants are briefly discussed below.
Untreated or undertreated insomnia and other sleep disorders, including obstructive sleep apnea, are common and frequently overlooked. Disrupted sleep not only worsens depressive symptoms but can also reduce response to antidepressant treatment.
Active substance use, including alcohol, can interfere with treatment response and independently maintain depressive symptoms. Co-occurring psychiatric conditions—including anxiety disorders, PTSD, ADHD, personality disorders, and unrecognized bipolar disorder—can further complicate the clinical picture and contribute to persistent symptoms despite appropriate antidepressant treatment.
Finally, underlying medical conditions such as hypothyroidism, chronic pain, nutritional deficiencies and other systemic illnesses can cause depressive symptoms that will not resolve with psychiatric treatment alone.
A recommendation for TMS begins with a comprehensive psychiatric evaluation. Dr. Bowers reviews your diagnosis, current symptoms, treatment history, medications, medical history, and any safety considerations that could affect care.
The goal of this evaluation is to choose a treatment plan that is suitable for your unique history and mental health goals. Some patients may be better suited for standard rTMS, and others may be candidates for iTBS or Accelerated TMS. Some patients may benefit from augmentation with medication or other interventions alongside TMS.
At The Mind Grove TMS Center, standard rTMS, iTBS, and Accelerated TMS may be considered for qualifying patients with treatment-resistant depression.
TMS is a noninvasive treatment that uses magnetic pulses to stimulate targeted brain regions involved in larger mood-related networks. It does not require anesthesia or sedation.
Evidence-based clinical guidelines include rTMS among potential treatment options when adults with major depressive disorder have not improved enough after 2 or more adequate medication trials. That does not mean TMS is appropriate for every person. Dr. Bowers considers whether it fits your diagnosis, treatment history, safety profile, and current care plan.
Standard rTMS is one of our core TMS protocols. A full course typically includes 36 to 40 sessions, delivered daily over four to six weeks, followed by a taper phase. The overall course typically spans eight to ten weeks, and appointments are approximately 20 to 40 minutes.
Intermittent theta-burst stimulation, or iTBS, is a form of rTMS that uses rapid theta-burst stimulation patterns. Each appointment is approximately 20 minutes total, with about 3-10 minutes of stimulation.
Accelerated TMS uses iTBS or standard rTMS as its delivery method. Our Accelerated TMS protocol includes five sessions per day for six treatment days within a 14 day period, followed by 2 treatments per week, for a total of 36-40 treatments. Each appointment is approximately 20 minutes, with about 3-10 minutes of stimulation. Alternative accelerated schedules will be considered on a case-by-case basis.
During treatment, we monitor progress with standardized screening tools and follow-up appointments.
Medication may remain an essential part of treatment for TRD. Some patients continue their current medication regimen during TMS, others may benefit from medication adjustments, augmentation with medications or other interventions.
At The Mind Grove, we consider how medication fits into the larger treatment plan rather than treating it as separate from the rest of your care.
The Mind Grove TMS Center is a physician-led, TMS-focused practice within an integrative psychiatric care model.
Dr. Bowers is dual ABPN board-certified in Adult Psychiatry and Child and Adolescent Psychiatry. Her background includes medical and graduate training at NYU School of Medicine, a postdoctoral research fellowship in Neurobiology at the University of Zurich, Adult Psychiatry residency at Georgetown University Hospital, and Child and Adolescent Psychiatry fellowship at Georgetown University Hospital.
That background informs a careful approach to treatment-resistant depression—one that considers diagnostic clarity, TMS, medication management, and the factors that may be affecting your progress.
We use MagVenture technology for TMS treatment in Colorado Springs.
Insurance coverage may be available for qualifying patients receiving TMS for depression-related indications. Coverage varies by diagnosis, payer requirements, and medical-necessity criteria.
Colorado Medicaid does not cover TMS.
Treatment-resistant depression is commonly used to describe major depressive disorder that has not responded adequately to medications or therapy. Definitions can vary, so Dr. Bowers reviews your individual treatment history rather than relying on one rigid definition.
Sleep problems, co-morbid mental health conditions, medical conditions,, medication side effects, medication adherence, and diagnostic uncertainty can all affect treatment planning. A comprehensive evaluation helps clarify which factors may be relevant to your symptoms and care.
Yes. Medication can remain part of care when it supports the treatment plan. Some patients continue medication during TMS, while others may benefit from medication changes, augmentation, or another clinical recommendation.
Coverage may be available for qualifying patients receiving TMS for depression-related indications. Coverage varies by diagnosis, payer requirements, and medical-necessity criteria. Colorado Medicaid does not cover TMS.
Dr. Bowers evaluates adults and adolescents ages 15 and older for depression-related TMS care. Candidacy depends on age, diagnosis, clinical history, safety considerations, and the applicable FDA-cleared indication.
This page is for informational purposes only and does not constitute medical advice, diagnosis, or treatment. Treatment-resistant depression and TMS care require evaluation by a licensed clinician who can review symptoms, diagnosis, medical history, medications, prior treatment, and safety considerations. TMS is not appropriate for every patient or every condition. If you are experiencing a medical or psychiatric emergency, call 911 or go to the nearest emergency department.
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