When Dr. Chris Aiken opened a psychotherapy practice in Western North Carolina, treatment-resistant depression wasn’t a specialty he planned for — it was what walked through the door. Most patients arrived having already failed one or more SSRIs prescribed in primary care. The standard next steps — raising the dose, switching classes, adding bupropion, buspirone, or a stimulant — often weren’t enough.

Somewhere between 30 and 60% of patients do not reach full recovery after two or more antidepressant trials. That wide range, drawn from different interpretations of the STAR*D trial, reflects just how varied this population is: older adults with vascular disease, patients with bipolar features, inflammation, insulin resistance, dysthymic temperament, childhood trauma, chronic stress. These depressions are complex and demand a multi-angled approach — lifestyle, nutrition, sleep, medication, psychotherapy, and sometimes neuromodulation.

That clinical reality led Dr. Aiken to seek out underused, evidence-backed options that don’t always make it into standard algorithms. This 2-part Hidden Gems series spotlights one of the most compelling: pramipexole, a dopamine agonist with growing evidence for treatment-resistant depression.

Both episodes are hosted by Dr. Aiken and Kellie Newsome, PMHNP, free to listen, with full transcripts on each episode page. Follow Dr. Aiken for daily clinical updates:

Both Episodes — Hidden Gems: Pramipexole

• 
  
  Part I Hidden Gems: Pramipexole Part I

  New research moves pramipexole up in the algorithm for treatment-resistant depression. The case for reconsidering this dopamine agonist.

• 
  
  Part II Hidden Gems: Pramipexole Part II

  Pramipexole has earned its place higher in the treatment-resistant depression algorithm. Now learn exactly how to use it — dosing, titration, monitoring, and what to watch for.