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Perspectives on Managing Treatment-Resistant Depression

doctor talking to female patient
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Part of the art of connecting in a meaningful way with a depression patient is to convey empathy for their current situation and hope for the future, while also tempering that by sharing appropriate expectations. When I’m working with a patient to find the most effective treatment for them, I constantly go back to one thing: what’s the truth? The truth is that there is a decent chance people can get better by trying something new, whether that’s medication or talk therapy or making a life change, or all of the above. But the truth is also that depression is a chronic condition. It doesn’t have a cure. It can wax and wane, and there is a small subset of people who don’t get better, who may have repeated hospitalizations, suicide attempts, and struggle to improve despite trying many treatment options; they may be ultimately diagnosed with treatment-resistant depression.

In my practice, when managing patients with treatment-resistant depression, establishing a trusting and open relationship is crucial. I strive to create a space in which patients can share their perspective and experiences, and I can respond to them conveying hope and telling them the truth at a time and in a way they can hear it.

Understanding Each Patient’s Individual Situation

Landing on the right treatment for a patient with depression can be difficult in some cases, but it’s nearly impossible if you as the psychiatrist don’t have all the information. In-depth conversations are key. If a patient has treatment-resistant depression, it’s important to avoid making an error in either of two extreme directions.

One direction I often see in psychiatric care is that the psychiatrist moves too quickly onto trying one new medication after the other. In some cases, this might be an appropriate treatment move, but it allows the doctor to side-step an important conversation in which they explore a patient’s circumstances as well as discuss the fact that there is a diminishing likelihood medications are going to help, and other adaptations to one’s life might need to be made.

Without a full view of the situation, we won’t be able to appropriately tackle the challenges a patient is facing. As psychiatrists, we must be active listeners and start with open-ended questions. Have a learning mindset and convey to the patient that you respect what’s on their mind and you’re open to discussing it. Take extra time and care to listen and restrain yourself from only giving advice. As physicians, we’re used to being the experts. We’re highly trained and educated in our field, and we think we know the right answer. It’s possible we don’t. Ask that extra question or two, and listen to what’s coming back.

In these conversations, a psychiatrist might learn that side effects have actually prevented a patient from adhering to their regimen, or it might become clear that more intensive cognitive behavioral therapy (CBT) would be beneficial. Additionally, a big life change might be necessary. A patient may need to go live with family for some time. They might not be able to take that stressful job or start a difficult school program. Medications are just part of a larger treatment plan that needs to take into account each patient’s circumstances. And this conversation sometimes gets avoided because the psychiatrist jumps too easily to suggesting another medication.

On the other extreme, there’s a risk that a doctor will throw up their hands and say, “Nothing’s working here. There’s nothing more I can do.” That’s very deflating and disconcerting for a patient. In these cases, I’ll share that the situation is beyond my expertise, but I will refer the patient to a trusted  colleague who might be better suited.

That conveys support and hope while acknowledging the reality of the situation.

Avoiding these two extremes can be difficult, and my strategy is typically to have an in-depth conversation with a patient in which I tell them there are other things we can try from a medication standpoint, while also imparting that these therapies are unlikely to be a cure or a full solution, so we need to consider other modalities and life adaptations for a more holistic approach.

The Importance of Talk Therapy

In addition to having detailed conversations, engaging patients in psychotherapy is crucial–it improves medication efficacy and is an essential depression management tool on its own. If you’re not suggesting the patient tries a psychotherapy modality like CBT, they’re not getting full treatment. CBT is evidence-based. There are studies that show it’s just as effective or in some cases more effective than medication for various forms of major depression. Reshaping a patient’s mindset or viewpoint of the world and their role in it can significantly impact their depression symptoms and ability to adhere to their medication. Patients are just not getting the appropriate or optimal care if psychotherapy isn’t being provided to them. If we have tunnel vision as psychiatrists about medication management only, sometimes supplemented by TMS or ECT, then we’re not living up to our full responsibility to suggest or provide all evidence-based treatments. That’s a real problem, especially with treatment-resistant depression, for which we’ve got to consider everything if the person is not easily getting better.

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THIS CONTENT DOES NOT PROVIDE MEDICAL ADVICE. This content is provided for informational purposes and reflects the opinions of the author. It is not a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of a qualified healthcare professional regarding your health. If you think you may have a medical emergency, contact your doctor immediately or call 911.