Managing Patients With Treatment Resistant Depression - Episode 2

Case 1: An Overview of Treatment Resistant Depression

Drs Harding and Halaris provide an overview of treatment resistant depression, including prevalence and determining a diagnosis.

Lisa Harding, MD: This brings up a good point when we look at the biopsychosocial model of how we approach our patients. With presentations where the patient was also involved in psychotherapy, was it the right kind of psychotherapy? I find that that also plays an important part in a patient’s overall wellness. Are they getting CBT [cognitive behavioral therapy] when they should be getting DBT [dialectical behavior therapy]? It’s important to look at the patient as a whole.

When we think about the prevalence of treatment-resistant depression, we go back to thinking about our landmark STAR*D clinical trial. The takeaway point from that clinical trial was that a third of our patients won’t respond to our treatment regimens. When we look at this patient, he definitely meets the qualification for treatment-resistant depression having answered your questions and mine. Was this a full work-up in terms of a good diagnostic psychiatric interview? Were the medical causes ruled out? Given that, by the time he would’ve tried and not responded to 2 antidepressants, for an adequate dose and duration, that is the consensus definition that we have right now for treatment-resistant depression.

Angelos Halaris, MD, PhD, APA, ACNP, CINP: Absolutely correct. I couldn’t agree with you more. Taking a thorough psychiatric history and developmental history for any age group, especially someone as young as this 26-year-old man, assessing childhood trauma, mistreatment, abuse, parenting, and family relations are all critical factors that predispose an individual to chronic relapsing nonremitting depression that must be addressed. The best way to address these issues is through psychotherapy. That also depends on what the individual’s psychiatric, family, and developmental history is like. Certainly, psychoanalytic and psychodynamic therapy shouldn’t be excluded. It takes longer and is a major investment, but in my experience, it works and pays off. DBT and CBT could be also considered, and should sometimes be considered in combination. Most definitely, supportive therapy should be done in conjunction with pharmacotherapy. I’m a very strong believer in combined pharmacotherapy with psychotherapy.

This transcript has been edited for clarity.