How do you approach treatment-resistant depression and anxiety related to menopause refractory to SSRI/SNRIs and hormone replacement therapy?

First, I try bupropion and have found that the dopaminergic medication is excellent for refractory depression, especially as one ages because dopamine gradually decreases 10% per decade (Berry et al., PMID 27807030). If bupropion doesn't help, then I have used pramipexole quite effectively over the last 25 years. The key is to start low and gradually increase the dose to minimize side effects. Besides its effect on mood, it also improves cognition and executive functioning and can increase sexual arousal as well (Tundo et al., PMID 37109571).