Confounding Factors in TRD (Part 1): The Role of Subtyping and Bipolarity

In psychiatric practice, treatment-resistant depression (TRD) is not unusual. In his 2008 review of the various definitions for TRD, including that of adequate clinical trials of at least 1 antidepressant, and perhaps 2, Barbee¹concluded with the view that the simplest definition of TRD is “failure to achieve a response to a medication to any degree short of remission.” We can gain much by stepping back from a patient with TRD and doing a careful assessment for complicating factors that can prevent remission of depressive symptoms.

In this 2-part article (see "Confounding Factors in TRD Part 2: Comorbidities and Treatment Resistance"), we discuss a number of the most common confounding factors of TRD. Here we look at subtyping and bipolarity and their role in TRD. Personality factors also affect treatment response in patients with depression. Unrecognized (or ignored) comorbid Axis II pathology, such as borderline personality disorder (BPD), can closely mimic various Axis I depression diagnoses, to the point where the clinician questions whether persistent or lingering dysphoric states are truly “depression.” In Part 2, we will discuss comorbidities in depression and their role in treatment resistance.

Outcomes are worse for patients with a history of childhood adversity or for patients who are in stressful or untenable psychosocial situations (eg, an abusive relationship, an ongoing custody battle). Depressive illnesses are both common and difficult to eradicate in such patients without attention to the “whole picture.” Poor treatment responsiveness is also associated with lack of social supports. Likewise, when the incentives, conscious or unconscious, for the “sick role” and psychiatric disability are greater than the rewards of euthymia, clinicians can easily find themselves thwarted in their treatment attempts.

SUBTYPING AND BIPOLARITY

Melancholic features in TRD

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