Psychiatry’s Dirty Secret: When Remission Becomes a Lie

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I am not afraid to tell a patient that we’ve reached the point of futility.

That word makes psychiatrists squirm. Futility. It feels like failure, like admitting defeat. But let me be brutally honest: in some cases of depression, after decades of failed medication trials, multiple rounds of electroconvulsive therapy, transcranial magnetic stimulation, augmentation strategies, and experimental off-label concoctions, continuing to sell the dream of full remission is a lie—and our patients know it.

The Cult of Remission

In psychiatry, we have elevated “remission” to near-religious status. We preach it, chase it, and punish ourselves when we do not achieve it. But here is the uncomfortable truth: for some patients, remission is not a realistic outcome. And in those cases, our relentless pursuit does more harm than good.

The naysayers will cry: But what about another course of ECT? What about psychedelics? What about ketamine? Pull out all the stops, right? No. Throwing the kitchen sink at a patient who has already tried it all is not heroic, it is reckless. It is practicing medicine as if desperation were a strategy.

Futility Is Honesty, Not Abandonment

So, where is the sweet spot? It is not about surrendering treatment, and it is not about endless escalation. Futility is honesty, but honesty with compassion. It is about recognizing that the standard of full remission may not be achievable and redirecting toward what is a reasonable treatment goal.

For some patients, that means managing residual symptoms so they do not destroy quality of life. For others, it means shifting the focus toward meaning, relationships, and functionality. The sweet spot is where we do the best for our patients: balancing realism with hope, offering evidence-based care while avoiding false promises, and never losing sight of the human being behind the diagnosis.

The Systemic Problem: Insurance and Workforce

Of course, there is a bigger elephant in the room. Patients with treatment-resistant depression often have not had high-quality psychotherapy, not because they do not need it, but because they cannot access it. Insurance companies undervalue therapy, reimburse poorly, and incentivize psychiatrists to focus on 15-minute med checks instead of hour-long psychotherapy sessions.

Medical schools and residency programs reinforce this divide, prioritizing pharmacology and neuromodulation over the hard, messy, but transformative work of psychotherapy. We should be training and incentivizing psychiatrists to deliver psychotherapy or at least ensuring they can connect patients to therapists who are both skilled and accessible. Until payers and training programs recognize psychotherapy as central to outcomes, we will keep overprescribing and underdelivering.

What About New Treatments?

Some will argue that newer treatments such as psychedelics, ketamine derivatives, neurostimulation devices might finally break through where others have failed. Maybe they will. I am not dismissing innovation. But here is my take: psychiatrists need to know when to give these options a fair trial and when to stop chasing the next miracle cure.

Yes, try the new treatment if it is evidence-based and accessible. But if a patient has exhausted multiple modalities without meaningful improvement, we need to step back and ask: Are we helping, or are we harming by extending the cycle of hope and disappointment?

Engaging Patients in the Process

This is where shared decision-making matters. Patients need to be part of the conversation, not passive recipients of whatever “next big thing” we prescribe. I tell my patients: Here are the options. Here is what the evidence says. Here is what it does not. What matters most to you?

Sometimes patients still want to try another treatment, and that is okay. But when they understand the risks, limitations, and likely outcomes, they can make choices that align with their values. Futility, in this sense, is not closing a door, it is opening a different one.

Psychiatry Needs More Courage

The truth is psychiatry has grown too timid. Too many clinicians would rather endlessly prescribe than risk saying, “We may never get to full remission.” But pretending a cure is always just a pill away is worse than pessimism—it is false hope.

What our field needs is courage. Courage to balance innovation with realism. Courage to challenge insurers and training programs that undervalue psychotherapy. Courage to be honest with patients, even when the truth is hard.

Because the sweet spot is not about chasing the impossible. It is about helping people live full, meaningful lives even in the presence of suffering. That is not futility. That is psychiatry at its best.

Dr Rossi is an inpatient and consultation liaison psychiatrist who also performs electroconvulsive therapy services at AtlantiCare Regional Medical Center in Pomona, New Jersey. He currently serves on the board of the New Jersey Psychiatric Association, where he has worked on advocacy projects, including enhancing access to collaborative care in the state.