The holidays can be a difficult time of year for many people, but not all seasonal sadness is the same. While the “holiday blues” are typically brief and situational, issues such as seasonal affective disorder (SAD) and major depressive disorder (MDD) are serious mental health conditions requiring professional care from a depression psychiatrist.
 
Whether it’s a temporary situation or something more serious, the symptoms are extremely unpleasant. Let’s take a look at each of these issues to gain a deeper understanding of how symptoms can be managed.
 
Before we dive in, though, if your symptoms include thoughts of death or suicide, please get help immediately. The national crisis hotline can be accessed by calling or texting 988, and help is available 24/7.
 
The Holiday Blues
While a myriad of songs tell us that the holiday season is the most wonderful time of the year, this is often simply not the case. The holidays bring with them a huge amount of stress and often high expectations of an idealized version of the season.
 
Additionally, for those with few family members or friends or those who have recently lost a loved one, this season can be extremely traumatic. Of course, family tension also can play a role in triggering the holiday blues, as it can be highly stressful and upsetting to navigate family get-togethers.
 
Of course, this “gift-giving” season also brings with it a financial burden that can cause huge amounts of stress, particularly if you are struggling financially. The season also brings with it disruptions in our daily routines, and while parties and special events can be enjoyable and meaningful, disrupted routines can alter our moods.
 
With all of that, it’s little wonder why some people experience unpleasant emotional symptoms at this time of year. Some common symptoms of the holiday blues include:

• Low mood
• Irritability
• Fatigue
• Mild Anxiety
• Feeling overwhelmed

 
The good news is that these feelings typically pass once the holidays are over and we return to our regular routine. There are also some steps we can take to minimize these unpleasant feelings during the holidays.
 
1. Keep Your Expectations Realistic
We are barraged by idealized versions of the holiday season on television and on social media, but these are not images that reflect reality. It is perfectly normal to feel stressed out or emotional during this time of year, and it’s also ok to scale back your celebrations to something manageable and comfortable.
 
2. Set Boundaries
Along these same lines, overcommitting can lead to burnout, and it is 100% acceptable to decline invitations to events that feel overwhelming. It’s also perfectly fine to limit time with stressful individuals.
 
3. Maintain Basic Routines
With the holidays, we tend to have our schedules disrupted, but, as much as possible, stick to a consistent routine. Keep consistent sleep and wake times, and keep mealtimes as regular as possible.
 
A bit of daily exercise can help as well, particularly going outside, especially if you live in an area with limited daylight during the winter months. Exposure to fresh air and sunlight can lift our mood.
 
4. Stay Connected
For many, many people, the holidays are a time of loneliness. It is important for people to stay connected with others, but this is not always easy. If family members are far away and cannot be seen in person during the holidays, set up time for a phone call or a FaceTime call. You can even schedule an online event with friends and family, if access in-person is difficult.
 
If you don’t have a strong network of friends or family, consider going to a house of worship to be around others or taking part in community activities. Volunteering is an excellent way to stay connected, and you will be brightening others' lives as well. Consider volunteering at a shelter, food bank, or perhaps a facility for the elderly.
 
4. Acknowledge Loss & Grief
For many of us, the holidays can exacerbate feelings of grief or loss. Whether the grief is due to a recent loss, strained family relationships, or just past losses, it’s ok to acknowledge that you feel grief. Suppressing these feelings can cause great emotional strain, so give yourself some space to grieve. As a depression doctor, I find that joining a support group can help provide you with a safe space to talk about these feelings of loss.
 
5. Plan Something for the Future
Whether you struggle to get through the holidays or tend to feel a huge letdown once the season ends, having something to look forward to can help improve your mood and maintain emotional balance.
 
This doesn’t have to be a huge event, just something manageable that you will enjoy. It could be as simple as a salon appointment for a new haircut, a lunch date with a friend (it’s often easier to schedule after the holidays), a scenic drive, a nature walk, trying out a new class, or even setting a few manageable goals for the new year.
 
Major Depressive Disorder
While the holiday blues typically pass fairly quickly after the holidays, Major Depressive Disorder (MDD) does not, and it tends to interfere much more intensely with our ability to manage our day-to-day life.
 
Common symptoms of MDD include:

• A depressed mood most of the day and nearly every day
• Loss of interest or pleasure in events you previously enjoyed
• Sleep and appetite changes (also significant weight loss or gain)
• Low energy
• Feelings of worthlessness or guilt
• Difficult concentrating
• Thoughts of death or suicide (Again, please call or text 988 if you are experiencing these thoughts now)

 
In general, with MDD, these symptoms persist for at least two weeks and often much longer, and these symptoms significantly impact daily functioning, including work and relationships with friends, family, and co-workers.
 
This is one of the main differences between holiday blues and MDD. With MMD, the symptoms greatly interfere with daily life. With holiday blues, we may experience unpleasant mood changes, but typically, we can still function and handle daily tasks.
 
MDD must be diagnosed by a professional, such as a depression psychiatrist. I recommend that you find a psychiatrist or ask your primary care physician to refer you to a local psychiatrist.
 
While a therapist and a psychologist can provide you with valuable therapy and tools to help manage symptoms, a psychiatrist is the only mental health professional who can prescribe medication for MDD, which may be needed.
 
Additionally, as we are also medical doctors, we can provide a more comprehensive diagnosis. In some cases, physical issues or other medications could be causing your symptoms, including drug or alcohol use. In other cases, you might suffer from multiple mental health conditions, and all of this must be treated properly.
 
Medication management can be an excellent tool, and we have many medications available that can reduce symptoms. There are also other options to consider, especially with treatment resistant depression, such as transcranial magnetic stimulation (TMS), electroconvulsive therapy (ECT), and more.
 
Of course, as a psychiatrist for depression, I also strongly encourage all of my patients to find a good therapist or psychologist for talk therapy. Cognitive behavioral therapy (CBT) and other types of therapy can help you manage symptoms, and your psychiatrist can provide you with medication options or additional types of treatment, if needed.
 
Seasonal Affective Disorder
It’s not the holiday blues, and it typically doesn’t last beyond the winter months as MDD might, but Seasonal Affective Disorder (SAD) can be difficult to navigate all the same. Typically, SAD occurs during the fall and winter, and this disorder is classified as a type of depression with a seasonal pattern.
 
While many people feel a bit down during the winter months, often due to less sunlight and less accessibility to outdoor activities, people with SAD tend to suffer from symptoms that interfere with daily functioning, just as you would with any type of MDD. The symptoms can include:

• Low mood
• Low energy or fatigue
• Increased sleep
• Increased appetite
• Weight gain
• Social withdrawal
• Difficulty concentrating

 
Generally, with SAD, light therapy is one of the first treatments we try, and a depression psychiatrist can recommend some light box options as well as guidelines for use. Generally, people use these for about 30 minutes every morning and often see improvement within just a week or two.
 
Psychotherapy can be a great option, as well, and there is a type of cognitive behavioral therapy developed just for people with SAD (CBT-SAD). This can help an individual not only deal with symptoms but also help reduce the likelihood of depression returning in the future.
 
Medication may be prescribed by a depression psychiatrist, but often this is just for moderate to severe cases, especially when other treatments have not been effective. Sometimes, a patient will start medications a few weeks before the symptoms typically arrive to prevent SAD.
 
Struggling With Depression? I Can Help
If you need a psychiatrist for depression, I work as a psychiatrist in Thousand Oaks, as well as a psychiatrist in Westlake Village. In addition to treating depression, I also work as a psychiatrist for anxiety, a psychiatrist for bipolar disorder, and many other mental health conditions, including addiction, eating disorders, adult ADHD, and more.
 
Whether you are searching for a depression psychiatrist or a doctor to help with other mental health conditions, I encourage you to give me a call, and we will get you on a path to a happier life. 

Bipolar disorder is a complex mental illness that requires expert care and support. As an experienced bipolar psychiatrist, I know that finding a psychiatrist and therapist are crucial components of treatment, but there are a few other helpful resources that I can recommend for people with this disorder as well as their loved ones.
 
When it comes to resources, it’s important to be cautious about where you seek help. It can be tempting to head to social media sites and forums or even scroll through random medical sites, but these often contain erroneous information that can cause more harm than good. Instead, you need to rely on legitimate, vetted mental-health resources, and here’s why.
 
1. Accurate Evidence-Based Information
Treating bipolar disorder or any type of mood disorder is complicated. Legitimate mental-health organizations and medical institutions use peer-reviewed research, clinical guidelines, and expert oversight. Social media posts, influencers, or unverified blogs often rely on personal opinion, anecdote, or misinformation, which can lead to harmful decisions about medications or symptoms.
 
2. Safety in Treatment Guidance
Trusted sources explain safe treatment options, medication side effects, and when to seek emergency help. This can put someone at risk of relapse, hospitalization, or severe mood episodes.

• Unverified sites may promote:
• Dangerous supplement combinations
• Unrealistic “cures”
• Advice to stop medication abruptly

 
3. Protection from Stigma and Harmful Myths
Legitimate organizations work to reduce stigma, support families, and provide compassionate help.

• Social media can spread:
• Stereotypes (“bipolar people are unpredictable” etc.)
• Harmful labels
• Insensitive or triggering comments

This can worsen shame, anxiety, or isolation. Reading these stigmas and myths also can make it more difficult for loved ones to provide compassionate support. Shame is a huge reason why people with mental illnesses avoid seeking help, but proper care can greatly reduce symptoms and improve your quality of life.
 
4. Balanced Perspectives (Not Extreme or Oversimplified Advice)
Good resources aim for balanced, nuanced mental-health education.
In contrast, social media and random internet sites often amplify:

• Extreme stories
• “All meds are bad” narratives
• “This one supplement cured me” posts
• Influencers with no medical training

 
Information from dubious sources can distort someone’s understanding of bipolar disorder.
 
5. Better Outcomes and More Informed Decisions
Misinformation can delay treatment and worsen outcomes. However, accurate education leads to:

• Better stability
• More effective treatment plans
• Earlier recognition of symptoms
• Stronger support for loved ones

 
The internet is full of information about bipolar disorder, but what resources can you trust? As a bipolar disorder psychiatrist, I recommend the following resources as they provide the most helpful, fact-based information about bipolar disorder as well as many other mental illnesses.
 
National Alliance on Mental Health (NAMI)
NAMI is the largest mental health organization in the United States, with more than 650 affiliated organizations nationwide. On the NAMI website, you can find educational resources and support groups both for people with a mental illness as well as family members and loved ones.
 
As a psychiatrist in Thousand Oaks, I often recommend NAMI to patients. For residents in the Thousand Oaks area, NAMI of Ventura County can provide resources and support. Just head to https://namiventura.org/. I also serve as a psychiatrist in Westlake Village, and https://namiglac.org/ is the website for NAMI of Greater Los Angeles.
 
On either website, you can find details about upcoming support group meetings (both in-person and virtual), as well as classes and webinars, and all of these resources are free. The websites also include a Resources section with information and psychiatric care, crisis support, education and much more.
 
NAMI also runs the National Hotline for Mental Health Crises and Suicide Prevention. If you are experiencing a mental health emergency, you can access this hotline by the following methods:

• Call or text 988 on your phone (Available 24/7)
• Text “NAMI” to 62640 (Available Monday-Friday, 10 a.m.-10 p.m. ET)
• Call 1-800-950-6264  (Available Monday-Friday, 10 a.m.-10 p.m. ET)

 
Depression and Bipolar Support Alliance (DBSA)
While NAMI provides support for all mental illnesses, DBSA concentrates solely on depression and bipolar disorder. For more than 40 years, this organization has been providing support for people with these mental health conditions as well as their loved ones.
 
On the DBSA website, at https://www.dbsalliance.org/, you can find educational resources for depression, bipolar disorder, anxiety, and co-occurring conditions. The website also includes links to informational podcasts and webinars on a wide variety of subjects.
 
Additionally, the website includes a Support section, where you can find support systems for adults, young adults, teens, and for friends and family members wanting to support a loved one with bipolar disorder or depression.
 
I particularly like the website’s Wellness section. There is so much misinformation out there about depression and bipolar disorder, but DBSA’s Wellness section provides research-based information about treatment options, therapy options, as well as the Wellness Wheel.
 
The Wellness Wheel is an interactive tool that encompasses different types of wellness, including spiritual, social, occupational, intellectual, environmental, financial and physical wellness. With the wheel, you can create goals to improve all of these areas, and to be honest, this is a great tool for anyone, regardless of whether or not they are dealing with a mental illness.
 
As a side note, if you need a psychiatrist for depression, I don’t just serve as a bipolar psychiatrist, but I also have extensive experience helping patients with depression, including treatment resistant depression. There are many new medications and therapy options these days, and I strongly urge you to get in touch with me so that we can find a treatment plan that helps you manage symptoms and improve your quality of life.
 
Why You Need A Psychiatrist For Bipolar Disorder
Bipolar disorder treatment usually involves the use of medication to help manage symptoms, which is why you need a psychiatrist. Psychologists and therapists cannot prescribe medication.
 
As medical doctors, psychiatrists are uniquely qualified to assess mental health symptoms while also identifying potential physical contributors, allowing for a comprehensive treatment approach.
 
Often, patients suffer from co-occurring mental health disorders, which can make medication management more challenging. Working with a psychiatrist can ensure that we select the best possible medication.
 
We are highly trained in pharmacology and have extensive education with psychoactive medications, and understand interactions between these types of medications, as well as any other medications you might be taking, such as blood pressure medicines, diabetes medications, etc. This is a huge reason to work with a bipolar psychiatrist rather than a general practitioner.
 
In general, I recommend seeing a bipolar disorder psychiatrist in person as opposed to virtually, especially during the early phases of diagnosis and treatment. Telepsychiatry has made it easier than ever for people to access mental health care, but, whenever possible, it’s usually best to meet face-to-face. Of course, if you are out of town or unwell, we can certainly talk via phone or online to ensure that you have consistent care.
 
Why You Need A Therapist/Psychologist For Bipolar Disorder
While a therapist or psychologist cannot prescribe medication, these professionals can be a hugely valuable resource for individuals with bipolar disorder, as well as any other mental health condition.
 
Therapists and psychologists can provide many different types of therapy, including cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), family therapy, trauma therapy (if needed) and Interpersonal and Social Rhythm Therapy (IPSRT).
 
While CBT and DBT can be very beneficial, IPSRT was developed specifically to treat people with bipolar disorder. This is an evidence-based therapy that helps to stabilize mood through the creation of consistent daily routines as well as improving interpersonal skills, such as communication skills,  learning how to adjust to major life changes, or dealing with conflict.
 
Get Help & Support Today!
Living with bipolar disorder can be difficult, but the good news is that there are some wonderful resources available. Working with a bipolar psychiatrist as well as a therapist, as well as taking advantage of resources from NAMI and DBSA, can transform your life. Don’t wait another day to seek help; bipolar disorder is treatable, and I am always here to get you started on the road to a happier, healthier life.  

When a friend or family member is suffering from a mental health condition, a local psychiatrist can be a huge help. However, support from loved ones can be just as crucial. As an adult psychiatrist who treats a variety of mental illnesses, I find that taking the following steps can be instrumental in making symptoms more manageable, as well as encouraging people to engage more fully in effective treatment options​​

Whether your loved one is dealing with a major depressive disorder, bipolar disorder, anxiety or another mental health condition, education can be a great first step to take. I encourage you to read reputable sources to help you understand the symptoms, treatment options and common challenges associated with a specific condition.
For example, as a bipolar disorder psychiatrist, I find it can be helpful for loved ones to recognize early signs of mania or depression, as this can help you more quickly encourage treatment and help you better understand the mood changes common to those with this disorder. Additionally, it can be smart to research tips and strategies to help your loved one through difficult times. ​

Psilocybin, often known as “magic mushrooms,” is a naturally occurring psychedelic compound found in some types of mushroom species. It is classified as a hallucinogen and has been used for centuries in spiritual and therapeutic practices.
When consumed, psilocybin is metabolized into psilocin in the body, which then binds to serotonin receptors in the brain. This interaction results in changes to perception, mood, and consciousness, often leading to visual and auditory hallucinations.​

A study at Washington University in St. Louis tracked changes in the brain before and after the use of psilocybin. The researchers found that a microdose of psilocybin had a profound effect on what is known as functional connectivity. This refers to how different regions in our brains communicate and work together to perform tasks or process information.
Essentially, it is postulated that small doses of psilocybin, given in controlled circumstances, might act as a sort of “reset” for our brains. Research suggests that psilocybin may boost our brain’s ability to reorganize and form new and healthier patterns of thought and behavior. It may help patients improve emotional processing as well as emotional regulation.

In our last blog post, we explored the general topic of treatment resistant depression (TRD), which affects millions of people around the world. For this article, let’s take a deep dive into one of the treatment options I consider in my practice as a depression doctor – pramipexole.

While feeling sad from time to time is an unavoidable part of life, people with depression, such as a major depressive disorder, experience persistent and overwhelming symptoms that interfere with daily functioning, relationships and overall quality of life.

If persistent feelings of sadness, depression or feelings of emptiness are reducing your enjoyment of life, there are many treatment options, including medications. However, for those with TRD, this is a form of major depressive disorder (MDD) that doesn't improve after trying at least two different antidepressant treatments, taken at adequate doses and duration.
​
In other words, even after following standard plans for treating depression, including medications and often talk therapy, people with TRD continue to experience significant symptoms of depression. TRD may require alternative approaches, one of which could be pramipexole.

This is a prescription medication that acts as a dopamine agonist, or rather, it mimics what dopamine does in our brains. Dopamine is a chemical messenger in the brain known as a neurotransmitter. It helps nerve cells send signals to each other and plays a key role in how we feel, move, and think.
​
Here are a few important things dopamine does:

• Movement: It helps control smooth, coordinated body movements. Low dopamine levels are linked to Parkinson’s disease.
• Mood and Motivation: Dopamine is part of the brain’s “reward system,” which makes us feel pleasure and motivation. It plays a role in how we experience happiness and satisfaction.
• Learning and Attention: It helps with focus, memory, and learning new things.

Too little dopamine can cause problems like depression or trouble moving. Too much dopamine may be linked to conditions like schizophrenia or addiction. Pramipexole was designed to help people with too little dopamine, specifically for those with Parkinson’s disease and Restless Leg Syndrome (RLS).

While pramipexole (brand names include Mirapex, Pexola and Sifrol) is FDA-approved for Parkinson’s and RLS, this drug has shown potential to help some people with treatment-resistant depression (TRD), especially when used as an add-on (augmentation) to standard antidepressants.

Here's how it may help:

• Dopamine support: Pramipexole boosts dopamine activity, which can improve mood and motivation, areas that often affect people with TRD.
• Clinical studies: Some small studies and case reports have found that adding pramipexole helped reduce symptoms of depression in people who didn’t respond to traditional treatments.

​Pramipexole tends to be best suited for people whose depression includes symptoms such as low energy, lack of motivation (anhedonia), or who haven't responded well to SSRIs or SNRIs.

Pramipexole is not FDA-approved specifically for depression, so it’s used off-label for TRD. The FDA approves medications for specific uses based on research. But once a drug is approved, doctors are legally allowed to use their medical judgment to prescribe it for other reasons if they believe it could help. Off-label use is common in psychiatry, especially when standard treatments haven’t worked.
Pramipexole is an excellent example. This drug is FDA-approved for Parkinson’s disease and RLS. But some doctors may use it off-label to treat treatment-resistant depression, because studies and experience suggest it might help, even though it wasn’t officially approved for that purpose.
If you're considering it for TRD, it should be discussed with a depression psychiatrist who has experience with off-label treatments. As an experienced depression doctor, I have found that pramipexole can be an excellent option for some patients with TRD.
Keep in mind that this drug, as with all medications, may come with potential risks and side effects. Here’s a quick look at some of the most common side effects as well as more serious concerns.

Common Side Effects of Pramipexole

• Drowsiness or sudden sleep attacks – Some people fall asleep without warning, even during the day.
• Dizziness or lightheadedness, especially when standing up (orthostatic hypotension).
• Nausea or upset stomach (this typically resolves within a few weeks of taking the drug)
• Fatigue or weakness
• Constipation
• Hallucinations – Seeing or hearing things that aren’t there, especially in older adults. (This side effect is more common in Parkinson’s patients or patients with a history of psychosis or bipolar disorder.)

Serious Risks

• Impulse control disorders – Some people may develop strong urges they can’t control, like gambling, excessive shopping, binge eating, or hypersexuality.
• Sleep problems – Including insomnia or abnormal dreams.
• Low blood pressure – Can cause fainting or falls.
• Confusion or changes in mood or behavior, especially in older adults or those with psychiatric conditions.

Special Caution
People with kidney problems may need lower doses since the drug is cleared from the body by the kidneys.
Because of these risks, pramipexole should always be taken under close medical supervision, especially when used off-label for conditions like treatment-resistant depression.

​Pramipexole can interact with several medications, which may increase side effects or reduce the effectiveness of one or both drugs. Here are some important categories and examples to be aware of:

Drugs that affect the brain or nervous system:
These can increase drowsiness, confusion, or the risk of hallucinations:
Sedatives (e.g., benzodiazepines like lorazepam or sleep aids like zolpidem)
Antidepressants (especially oral antidepressants such as tricyclics and MAOIs)
Antipsychotics (e.g., haloperidol, risperidone) may reduce pramipexole’s effects
Other dopamine agonists (risk of additive side effects)
​
Drugs that lower blood pressure:
These can worsen dizziness or fainting from pramipexole:

• Blood pressure medications (e.g., lisinopril, amlodipine)
• Diuretics (e.g., furosemide)

Drugs that affect kidney function:
​Again, because pramipexole is cleared by the kidneys, drugs that impair kidney function can raise pramipexole levels:

• NSAIDs (e.g., ibuprofen, naproxen) in high or long-term doses
• Certain antibiotics (like aminoglycosides)

Other potential interactions:

• Alcohol: Can worsen drowsiness and dizziness.
• Cimetidine (used for heartburn): May slow pramipexole’s clearance, increasing its effects. This over-the-counter drug also is known by its brand name Tagamet.

Now that you’ve read about the risks, which can seem scary, let me assure you that not every patient experiences all or even any of those side effects. However, when I prescribe any medication for patients, it is crucial that they disclose all of the medications and supplements they are taking.  Additionally, if you use any recreational drugs – alcohol, marijuana, etc., it is important to disclose this as well.

Remember, I am here to help you, not to judge. Many people, especially those with mental health issues, turn to drugs or alcohol to alleviate symptoms. Unfortunately, alcohol and recreational drugs often can make mental illness worse and they often are dangerous to use in conjunction with prescribed medications and even some over-the-counter medicines.
​
As a depression psychiatrist, it’s crucial that I have all of the information so that I can create a truly effective treatment plan. Keep in mind, if you are struggling with drug use or alcohol use, I do work as an addiction psychiatrist, as well, and treating all of the issues you are facing is the best way to improve your life. It’s certainly not easy, but tackling these challenging issues can improve your level of happiness as well as your relationships with family and friends.

Typically, this drug is not given on its own but in combination with a standard antidepressant. Generally, it is prescribed along with one of the following classes of antidepressants.  These medications work on serotonin and/or norepinephrine, while pramipexole targets dopamine, providing a broader neurochemical effect.

Selective Serotonin Reuptake Inhibitors (SSRIs)
Sertraline (Zoloft)
Fluoxetine (Prozac)
Escitalopram (Lexapro)
Citalopram (Celexa)
​
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Venlafaxine (Effexor XR)
Duloxetine (Cymbalta)

Atypical Antidepressants
Bupropion (Wellbutrin) – especially common, since it also works on dopamine and norepinephrine
​Mirtazapine (Remeron) – sometimes combined to address sleep and appetite issues

If you are struggling with TRD, the first step is to reach out to a depression doctor for a thorough diagnosis. A psychiatrist can examine all aspects of your health, including physical and mental health issues, as well as review previous treatment plans.
Keep in mind, if I determine that pramipexole is not the right option for you, there are many other options these days for people with TRD. For instance, we might try intranasal ketamine, transcranial magnetic stimulation (TMS), electroconvulsive therapy (ECT) or perhaps even psilocybin.
Generally, as a psychiatrist for depression, I also recommend adding talk therapy and lifestyle changes to your treatment plan. Exercise, exposure to sunlight, meditation, proper nutrition and other steps can help people better manage the symptoms of major depression.

While it can take time to find the ideal approach for your TRD, there is hope, and many patients find that pramipexole or another treatment option greatly reduces symptoms and allows them to live a happier, healthier life.
If you are searching for a depression doctor, I can help. I work as a psychiatrist in Thousand Oaks, as well as a psychiatrist in Westlake Village, Simi Valley and throughout north LA county and southern Ventura county. I have extensive experience treating depression, including TRD, as well as anxiety, bipolar disorders, eating disorders, addiction and the complexity of treating co-occurring disorders.

Have you attempted several different treatments for depression yet still ask yourself why do I feel empty? These feelings of emptiness and despair can be overwhelming and confusing, and you may have what is known as treatment resistant depression, or TRD.
 
For those struggling with TRD, this emotional void can feel extremely isolating. Let's answer some common questions about TRD, explore why some people experience this persistent sense of emptiness, and discuss effective treatment options that may help restore hope and well-being.

First let’s talk about MDD, or Major Depressive Disorder, which typically is the first diagnosis you would receive. This serious mental health condition affects millions of people around the world.
 
Typically, the symptoms include persistent feelings of sadness, and/or hopelessness, and a loss of interest in previously-enjoyable activities  People with MDD often experience physical symptoms such as changes in sleep issues, loss of appetite (or increase), and a drop in energy levels.
 
To be diagnosed with MDD, these symptoms typically must last for at least two weeks and significantly impact a person’s daily life, relationships, or ability to function. MDD can vary in severity, with some individuals responding well to standard treatments like therapy and medication, while others may develop treatment-resistant depression (TRD).

To be honest, we don’t always know the specific reasons why depression occurs. Depression is a complex mental health condition with no single cause. Instead, it typically arises from a combination of biological, psychological, and environmental factors. Some common contributors include:

Biological Factors

• Brain Chemistry: Imbalances in neurotransmitters like serotonin, dopamine, and norepinephrine can affect mood regulation.
• Hormonal Changes: Hormone fluctuations, such as those occurring during pregnancy, menopause, or due to thyroid issues, can contribute to depression.
• Genetics: Individuals with a family history of depression may have a higher risk of developing the condition.

 
Psychological Factors

• Personality Traits: People with low self-esteem, perfectionism, or a tendency to ruminate may be more vulnerable.
• Unresolved Trauma: Past emotional or physical trauma can increase the risk of developing depression.

 
Environmental Factors

• Chronic Stress: Prolonged exposure to stressful situations, such as financial struggles, work pressure, or relationship conflicts, can trigger depression.
• Life Events: Major life changes — including the loss of a loved one, divorce, or job loss — are common triggers.
• Childhood Experiences: Adverse childhood experiences, such as neglect or abuse, can increase the risk.

 
Medical Conditions

• Chronic Illness: Conditions such as diabetes, heart disease, and chronic pain can contribute to depressive symptoms.
• Medication Side Effects: Certain drugs, including some blood pressure medications or hormonal treatments, may cause or worsen depression.

 
Lifestyle Factors

• Poor Sleep: Lack of restful sleep is closely linked to mood disorders.
• Substance Abuse: Alcohol, drugs, or certain medications can contribute to or exacerbate depressive symptoms. Of course, as an addiction psychiatrist, I often find that substance use disorders develop because a person is suffering from depression and drugs or alcohol are used to self-medicate.
• Nutritional Deficiencies: Deficiencies in key nutrients, such as vitamin D, omega-3 fatty acids, and B vitamins, have been linked to depression.

 
Social Isolation

• Limited social support or feelings of loneliness can increase the risk of developing depression.

 
Because depression can stem from multiple factors, effective treatment often requires a depression doctor to try a combination of therapies tailored to an individual's unique circumstances.

TRD is a form of major depressive disorder (MDD) that does not respond adequately to at least two different antidepressant treatments, taken at the appropriate dose and duration. Individuals with TRD may experience ongoing symptoms such as:

• Persistent sadness
• Fatigue
• Lack of motivation
• Emotional numbness

 These feelings persist despite trying multiple treatment approaches. Because TRD can be challenging to manage, it often requires a combination of therapies, specialized treatments, and expert care.

In this blog, the first in a series regarding TRD, we will briefly describe the various treatment resistant depression treatment options. As we dive further into the subject our next blogs will take a deeper dive into specific treatments, specifically some of the latest alternative treatments for people with TRD or depression in general.
 
But first, let’s take a quick look at the many different options psychiatrists can utilize to help patients with TRD. Keep in mind, that in many cases, it’s best to use a combination approach that includes multiple treatment options.

1. Switching Antidepressants
If one type of antidepressant doesn’t work, switching to another class of medications (e.g., from SSRIs to SNRIs) may be beneficial.
 
2. Combination Therapy
Using two different classes of antidepressants together can sometimes provide better results.

This entails adding non-antidepressant medications to enhance the effects of current treatment. Options may include:

• Atypical antipsychotics (e.g., aripiprazole, quetiapine)
• Mood stabilizers (e.g., lithium)
• Stimulants (e.g., methylphenidate)
• Thyroid hormones in some cases
• Ketamine or Esketamine (Spravato)
• Dopamine agonists (e.g. Pramipexole)

Ketamine for treatment resistant depression (often administered via IV infusion) and esketamine (a nasal spray) have shown rapid improvement in depressive symptoms, particularly in individuals with TRD. We will explore ketamine and specifically esketamine further on during our series about TRD. Pramipexole alone or in combination with other drugs, such as ketamine, is another subject we will explore more deeply in future blogs.

​1. Psychotherapy (Talk Therapy)
Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), and Acceptance and Commitment Therapy (ACT) may offer support when combined with other treatments. Again, as an experienced depression psychiatrist, I strongly recommend adding some type of talk therapy to any treatment plan.
 
2. Transcranial Magnetic Stimulation (TMS)
This is a non-invasive treatment where we use magnetic fields to stimulate the nerve cells in the brain. TMS has been found to be effective for some patients who haven’t responded to traditional medications.
 
3. Electroconvulsive Therapy (ECT)
ECT can be highly effective for severe TRD, particularly when other treatments have failed. Modern ECT is safer and involves controlled electrical currents under anesthesia.
 
4. Vagus Nerve Stimulation (VNS)
A device implanted in the chest sends electrical impulses to the vagus nerve, which can help regulate mood.
 
5. Deep Brain Stimulation (DBS)
Typically used for neurological conditions like Parkinson’s, DBS is now being explored for severe cases of TRD.

1. Exercise & Physical Activity
I know it can be tough for people with depression to get outside and get moving, but regular exercise has been shown to improve mood and overall mental well-being. I highly recommend trying to get outside and walking for at least 20 minutes per day. Sunshine, fresh air and a change of scene might not be a miracle cure, but they certainly can help improve your mood.
 
2. Mindfulness & Meditation
Practices such as mindfulness, meditation, yoga, or tai chi may reduce depressive symptoms.
 
3. Nutritional Support
Omega-3 fatty acids, vitamin D, and certain amino acids may provide additional support.
 
4. Light Therapy
This is especially effective for individuals with seasonal affective disorder (SAD) but can also benefit TRD patients.

1. Neurofeedback
This therapy trains individuals to regulate brainwave patterns.
 
2. Digital Therapeutics
App-based programs designed to support mental health may provide adjunctive benefits.
 
3. Biomarker Testing
Genetic testing may help identify which medications are most likely to be effective for an individual.

As a psychiatrist for depression, I understand how frustrating it can be to have treatment resistant depression. Many with TRD feel very hopeless, but generally, we can always find some type of treatment option that works, even if we need to veer away from some traditional therapies. If you are struggling with TRD and wondering “Why do I feel empty” despite several attempts at treatment, please contact me today and let’s find a new approach that can help you rebuild your life and mental health.
 
Whether you need a psychiatrist for TRD or perhaps a psychiatrist for bipolar disorder, anxiety, borderline personality disorder or another mental health condition, I work as a local psychiatrist for patients in Thousand Oaks, Westlake Village and surrounding areas. Don’t give up hope, together we can find a treatment plan that helps you live a better and happier life.