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6 | Health Matters: Providence St. Joseph Hospital A Ray of Hope Sometimes depression does not respond to antidepressants. But there are other options at Providence St. Joseph Hospital. I magine that you have been struggling for months, even years, with leaden sadness. Finally you get a diagnosis of clinical depression, and with renewed optimism you start an antidepressant medication … and it doesn't work. Then your doctor tries a different antidepressant, or maybe tries combining two— and you still feel depressed. The official medical term is treatment- resistant depression, or TRD. Ernest Rasyidi, MD, a staff psychiatrist at Providence St. Joseph Hospital, explains: "The definition will vary, but the one most accepted is someone with clinical depression who has failed with two medications, shown no or only partial improvement or found the side effects of medication intolerable." The first step in treatment for TRD, according to Dr. Rasyidi, is often self-referral, meaning the patient has been seeing a primary doctor or a psychiatrist and realizes they just aren't feeling better. "They contact our clinic and schedule an evaluation," he says, "and we confirm their diagnosis, medical history and current treatment. And then we decide on treatment." THREE OPTIONS FOR TREATMENT "The most mainstream option is transcranial magnetic stimulation, or TMS," Dr. Rasyidi explains. "We use a machine to create a magnetic field—somewhat like an MRI—and the field penetrates the skull. We then alter the currents, target certain areas in the brain that might be underactive and stimulate those areas. "The patient is fully awake and conscious the whole time—no anesthesia. We want them awake, because the procedure stimulates the brain. The time in the chair is brief: 20 minutes, five days a week, for six weeks." Option two is an intranasal ketamine dose. "This one is relatively new, and we have to monitor you for two hours afterward," explains Dr. Rasyidi. "A side effect of the treatment is that the blood pressure may go up, and that can cause other issues, such as heart attack or stroke. We want to make sure that doesn't happen." "We know that ketamine works on a neurotransmitter receptor called NMDA, but we don't fully understand how or why it works for some people and not others," he says. Ketamine treatments are administered twice a week for a month, then once a week for a month, then every two weeks for a month. Electroconvulsive therapy (ECT) is another option. ECT "is colloquially referred to as 'electroshock therapy,' " says Dr. Rasyidi, "and that's a negative connotation—it's not like One Flew Over the Cuckoo's Nest." A current is administered, while the patient is under anesthesia, to induce a seizure. "The seizure lasts a few seconds," he says. "The procedure is administered three times a week for two weeks, then twice a week for a week or two, then we continue to taper it down." Dr. Rasyidi explains: "We know that when you cause a seizure, you also cause an immediate, massive release of neurotransmitters such as serotonin, dopamine and norepinephrine, which stimulates genesis and reforms connections. It's like a tree starting to sprout new branches. Sort of a reset button." If you have been diagnosed with clinical depression and feel your treatment is not working or has plateaued, contact Behavioral Health Outpatient Services at 714-771-8085. Dr. Ernest Rasyidi

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