Patients with Treatment Resistant Depression (TRD) have more than one disease state at a time.  TRD is defined as a depression that has not improved with 3 or more psychotropic medications including antidepressants, mood stabilizers, stimulants or second generation antipsychotics. ​

This is probably makes up 50% of the treatment process.  The patient has to WANT to change for the better.  Change takes time, effort, commitment and patience.  These attributes will be tested during the sometimes long and arduous process of treatment. 
I always refer my patients to a good psychotherapist to help with this process.  A good therapist will be able to help with non-medications issues related to the patients psychological functioning.  There might be issues that get in the way especially with relationships with others and themselves.  Some common issues deal with accepting the illness, accepting treatment with medications, control issues, maladaptive behaviors, to name a few.

​ I’ve come to refine my treatment approach to my patients in the last 30 years.  I’ve been blessed with the ability to successfully treat most of them who have very complex multiple co-occuring disease states.  I am calling this treatment method “The Jesalva Algorithm.”