Still Depressed on Antidepressants in Winter?

Taking an antidepressant every day, doing everything right, and still feeling low as the days get shorter is one of the most common situations we see in January. It is also one of the most discouraging, because it can feel like the last option has already been used. It has not. This post explains why a medication can underperform in winter, what a fair trial actually means, and what a psychiatrist looks at next.

First, the reassurance

A partial response to a first antidepressant is the most common outcome, not the exception. In the largest study of antidepressant treatment in real-world patients, funded by the National Institute of Mental Health, about 37 percent of people reached remission on the first medication they tried, and about 31 percent of those who moved to a second step reached remission there (Rush et al., STAR*D, American Journal of Psychiatry, 2006). In plain terms, most people need more than one attempt, and needing more than one attempt is the ordinary path, not a sign that nothing will work.

That study also found something important for planning. Remission rates were lower at the third and fourth steps, and people who needed more steps were more likely to relapse (and this assumes a lengthy med trial for each step). That is the reason a psychiatrist does not want to spend a winter waiting to see whether a partial response improves on its own.

Why winter makes it worse on the same dose

A medication that held through summer can feel like it has stopped working in December. Often it has not changed at all. The season has. Less light shifts the body clock and lowers serotonin activity, as explained in Post 1 of this series on why seasonal depression shows up in Colorado. Less activity, less time outdoors, and more isolation stack on top. For a person with ongoing depression that is partly controlled, a seasonal pattern layered on top can be enough to bring symptoms back.

The early signs of that seasonal layer are usually physical before they are emotional: sleeping more, an afternoon crash, cravings for bread and sweets, canceling plans. Post 2 lists the signs that show up before the mood does. If those arrived on schedule this fall, the seasonal pattern is part of the picture, and treating it directly is part of the answer.

Five reasons an antidepressant may be underperforming

Not enough time yet. Most antidepressants take four to six weeks at a therapeutic dose before their full effect is clear, and some people need longer. A medication started in November may not have had its full chance by early January.

Dose never optimized. Many people are started at a low dose to limit side effects and are never moved up. A dose that is well tolerated is not the same as a dose that is working. If the dose has not changed since the first prescription, that is a question to ask.

Partial response accepted as “good enough.” Feeling somewhat better is real progress, and it is also where many people stop, because it is such a relief compared with before. Partial response leaves symptoms in place and, as the study above found, leaves the risk of relapse higher. The goal of treatment is remission, meaning the symptoms are gone, not just smaller.

An untreated seasonal pattern. If depression reliably deepens every winter, the medication may be treating the year-round depression while the seasonal layer goes untreated. Light therapy, seasonal therapy, or a medication adjustment timed to the fall can address that layer specifically.

Treatment-resistant depression. When two or more antidepressants have been tried at an adequate dose for an adequate time without adequate improvement, psychiatrists call the condition treatment-resistant depression. It is common, it has a name because it is well studied, and it has its own treatment pathway, described below.

What a fair trial actually means

The phrase “I tried that and it did not work” covers a wide range of experiences, and a psychiatrist will want to know which one. A fair trial means an adequate dose for an adequate time. Adequate dose means the medication was raised to the level where it is expected to work, not left at the starting dose. Adequate time means several weeks at that dose, long enough for the full effect to appear.

Many people who believe they have failed several medications have had a fair trial of one, a short trial of another, and a low-dose trial of a third. That matters, because it changes the next step. Sometimes the right move is a proper trial of something already tried. Sometimes the history shows that fair trials have already happened, and the next step is a different kind of treatment.

Bringing a list of what was taken, at what dose, and for how long makes the appointment far more useful.

What comes next when two medications have not worked

When fair trials of two or more medications have not produced remission, the conversation moves to treatments that work differently from a daily pill. Axis offers two, and both are covered by most insurance.

Deep TMS uses a magnetic coil placed against the head to stimulate the areas of the brain involved in mood, with no medication, no anesthesia, and no downtime. It is cleared by the FDA for adults with major depressive disorder who have not improved adequately on antidepressant medication. A winter course looks like short weekday sessions over four to six weeks. A course started in early January runs through the hardest weeks of the season and finishes as the days lengthen. Learn more on our Deep TMS page.

Spravato is a prescription nasal spray taken in the clinic under supervision, approved by the FDA for treatment-resistant depression in adults. Each session includes at least two hours of monitoring, and the schedule starts with two sessions a week for four weeks before sessions are spaced further apart. It acts on a different brain system than the medications most people have already tried. A winter course started in January covers February, which for many people in Colorado is the hardest month. Learn more on our Spravato page.

Post 4 in this series explains both options in detail, including what a full course looks like and who each one is for. If the main problem is feeling flat rather than feeling sad, Post 5 on emotional blunting addresses that directly.

How to bring this up at an appointment

Three questions cover most of what matters. Bring them written down.

Has this been a full trial? Ask whether the current medication has reached an adequate dose and been there long enough to judge.
Is there a seasonal pattern here? Ask whether the winter dip is a separate layer that should be treated on its own.
What are the options beyond another medication? Ask specifically about treatments that do not involve a daily pill, and whether your history qualifies.

A psychiatrist who hears these three questions has what they need to review the plan. The answers will usually point to one of the five reasons above. If the appointment is short, lead with the third question, because it opens the whole conversation.

How Axis handles it

The Axis intake is a 60-minute visit with a psychiatric provider that goes through the full medication history, dose by dose and winter by winter. That review is what separates a partial trial from a fair one and a seasonal layer from ongoing depression. Before any advanced treatment starts, a financial consult confirms coverage under your plan. Psychiatry, therapy, Deep TMS, and Spravato are all offered in one clinic, so the plan can change without a new referral or a new practice.

Intake appointments are covered by most insurance, and no referral is needed.

Not sure where to start? Call one of our four Colorado clinics or start with telehealth.

If you are having thoughts of suicide or of not wanting to be here, call or text 988 to reach the 988 Suicide and Crisis Lifeline. It is free, confidential, and open 24 hours a day. If you are in immediate danger, call 911.