If you live in New Jersey and have been struggling with depression that does not seem to get better — even after trying multiple antidepressants — you are not alone, and you have not run out of options. Treatment-resistant depression (TRD) affects millions of Americans, and right here in Central NJ, Dr. Mirza at Hamilton Psychiatric Services has been helping patients find a path forward for more than 30 years. This guide explains what TRD is, why some people do not respond to standard treatments, and what advanced options are available to you today.
What Is Treatment-Resistant Depression?
Treatment-resistant depression is typically defined as major depressive disorder that has not responded adequately to at least two different antidepressant medications taken at the correct dose for a sufficient period of time (usually six to eight weeks each). It is important to note that TRD does not mean untreatable depression — it means that the standard first-line approaches have not been sufficient for your particular biology, and that it is time to explore a broader set of strategies.
TRD is more common than many people realize. Research suggests that approximately one-third of patients with major depression do not achieve remission after two medication trials. If this sounds familiar, the most important thing to understand is that there are evidence-based, clinically proven options beyond the antidepressants you have already tried.
Why Don't Some People Respond to Antidepressants?
Depression is not a single, uniform condition. It is a complex syndrome with multiple potential underlying causes — and that complexity is part of why standard antidepressants work well for some patients and not others. Factors that can contribute to treatment resistance include:
- Genetic variation: Differences in how your body metabolizes medications (pharmacogenomics) mean that a standard dose of a standard drug may be too high, too low, or simply not the right mechanism for your neurobiology.
- Misdiagnosis: Depression that has not been accurately distinguished from bipolar disorder, ADHD, or a personality disorder may not respond to antidepressants because those conditions require different treatments.
- Underlying medical conditions: Thyroid disorders, chronic pain, sleep apnea, and other medical conditions can perpetuate depressive symptoms and blunt medication response.
- Psychosocial factors: Ongoing trauma, abusive relationships, financial stress, or grief can sustain depression in ways that medication alone cannot fully address.
- Neurobiological differences: Some individuals have variations in brain circuit function that respond better to non-pharmacological interventions like Deep TMS.
Understanding the specific reasons why you have not responded is a critical first step. This is why a thorough re-evaluation with an experienced psychiatrist — rather than simply trying yet another antidepressant — is so important.
Treatment Options for Treatment-Resistant Depression
Medication Optimization and Augmentation
Before concluding that medication has failed entirely, a psychiatric expert will evaluate whether previous trials were truly adequate. This includes reviewing whether the dose was therapeutic, whether the trial lasted long enough, and whether any factors (such as drug interactions or medical conditions) interfered with the medication's effectiveness.
When optimization alone is insufficient, augmentation strategies involve adding a second medication to a partially effective antidepressant. Common augmentation approaches include adding atypical antipsychotics (such as aripiprazole or quetiapine), lithium, thyroid hormone, or buspirone. These combinations can significantly improve outcomes for patients who had only partial responses to monotherapy.
Learn more about medication management at Hamilton Psychiatric.
BrainsWay Deep TMS Therapy
For patients who have not achieved adequate relief from medication, FDA-approved Deep Transcranial Magnetic Stimulation (Deep TMS) is one of the most significant advances in psychiatric treatment in recent decades. Hamilton Psychiatric Services is proud to offer the BrainsWay Deep TMS system — the only TMS technology proven to reach deeper brain structures associated with depression, including the subgenual cingulate cortex.
Deep TMS uses precisely targeted magnetic pulses to stimulate and normalize the activity of brain circuits that are underactive in depression. The treatment is:
- Non-invasive — no surgery, no anesthesia
- Outpatient — each session is approximately 20 minutes, and patients can drive themselves home afterward
- Well-tolerated — the most common side effect is mild scalp discomfort that typically resolves after the first few sessions
- Clinically proven — in FDA registration trials, BrainsWay Deep TMS achieved a 38% remission rate in patients who had failed at least one prior antidepressant
A standard course of Deep TMS consists of 36 sessions delivered five days per week over six to seven weeks. Dr. Mirza monitors patient response throughout the treatment course and adjusts the protocol as needed. Many patients begin noticing improvement within the first two to three weeks.
Learn more about Deep TMS therapy at Hamilton Psychiatric.
Psychotherapy Combinations
Research consistently shows that combining medication or TMS with psychotherapy produces better outcomes than either treatment alone — especially for treatment-resistant cases. Cognitive Behavioral Therapy (CBT) is particularly well-studied for depression and helps patients identify and change the thought patterns and behaviors that sustain depressive episodes.
For patients with trauma histories, PTSD-focused therapies such as EMDR or trauma-focused CBT may be essential components of treatment. For those whose depression is intertwined with ongoing relationship difficulties or major life stressors, interpersonal therapy and supportive psychotherapy can provide meaningful relief that pharmacological approaches cannot fully address on their own.
Pharmacogenomic Testing
Pharmacogenomic testing (sometimes called genetic testing for antidepressants) analyzes how your genetic makeup affects the way you process specific psychiatric medications. This can help identify medications that are more or less likely to be effective or cause side effects based on your individual biology. Dr. Mirza can discuss whether pharmacogenomic testing is appropriate for your situation and how to interpret the results.
How Hamilton Psychiatric Approaches Treatment-Resistant Depression
When a patient presents to Hamilton Psychiatric Services with a history of inadequate antidepressant response, Dr. Mirza takes a systematic, evidence-based approach:
- Comprehensive re-evaluation: Dr. Mirza reviews the full history of prior treatments, examines whether prior medication trials were truly adequate, screens for conditions that can mimic or worsen depression, and considers whether the original diagnosis should be revisited.
- Individualized treatment planning: Based on the re-evaluation, Dr. Mirza develops a prioritized treatment plan. This may include medication optimization, augmentation strategies, referral for pharmacogenomic testing, Deep TMS, psychotherapy, or some combination of these approaches.
- Close monitoring: Treatment-resistant cases require more frequent follow-up than straightforward depression. Dr. Mirza schedules regular check-ins to assess response, manage side effects, and make timely adjustments.
- Integration of TMS when indicated: Because Dr. Mirza offers BrainsWay Deep TMS on-site, there is no need to coordinate with a separate facility. TMS can be seamlessly woven into the overall treatment plan, and Dr. Mirza can oversee both medication and TMS simultaneously.
When to Seek a Second Opinion
If you have been in treatment for depression for a significant period of time without meaningful improvement, it may be time to seek a second opinion from a psychiatrist who specializes in complex and treatment-resistant cases. A second opinion is not a sign of distrust toward your current provider — it is a responsible step that many patients find provides clarity, new options, and renewed hope.
At Hamilton Psychiatric Services, Dr. Mirza offers second opinion consultations for patients who want an independent expert review of their diagnosis and treatment plan. These consultations are available in-person in Hamilton, NJ and via telehealth throughout New Jersey.
Request a second opinion consultation at Hamilton Psychiatric.
Frequently Asked Questions
How many antidepressants do I need to have tried before seeking TMS?
Insurance coverage for TMS typically requires failure of at least two antidepressant trials at adequate doses and durations. However, the clinical decision to pursue TMS depends on your individual history and circumstances — Dr. Mirza can help you determine when it is the right time to consider TMS.
Is TMS covered by insurance in NJ?
Most major insurance plans, including Medicare and many commercial insurers, cover Deep TMS for major depressive disorder when medical necessity criteria are met. Our office can assist with insurance verification prior to starting treatment.
How long does it take to see results from Deep TMS?
Many patients begin to notice improvement within the first two to three weeks of treatment, with continued improvement through the full six-to-seven-week course. Some patients respond more gradually. Dr. Mirza monitors your response throughout the treatment course.
Can I continue my current medications during TMS?
In most cases, yes. TMS is typically administered alongside existing medications. Dr. Mirza will review your current medication regimen and make any necessary adjustments before and during the TMS course.
What if TMS doesn't work either?
If a full course of Deep TMS does not achieve the desired response, there are still additional options available, including IV ketamine infusion (referral), electroconvulsive therapy (ECT) referral, and continued medication optimization. Dr. Mirza will discuss all available options with you at each stage of treatment.
Take the Next Step
Treatment-resistant depression can feel like a dead end — but it is not. With the right expertise, the right tools, and a personalized approach, meaningful recovery is achievable. If you are in New Jersey and have not found relief from standard antidepressant treatment, we encourage you to contact Hamilton Psychiatric Services today.
Call Dr. Mirza's office at 609-631-7770 to schedule a consultation. We serve patients in Hamilton, Trenton, Princeton, Lawrenceville, and throughout New Jersey via telehealth.