The Major Issues in Major Depressive Disorder

Despite the prevalence of disability, chronicity, morbidity, comorbidity, and premature mortality associated with MDD, most individuals with MDD receive inadequate—if any—treatment. Low-income and minority groups are especially unlikely to receive treatment. But even in high-income countries, World Mental Health surveys showed that only 22% of all individuals with 12-month MDD received minimally adequate treatment. Continue Reading

Diagnostic reliability has been a problem since DSM-1 and remains so through DSM-5-TR. MDD is a heterogeneous construct that limits communication, prognostic accuracy, and drug development, and it may be a key reason none of the current treatments are effective for more than about a third of those diagnosed with MDD. There are 227 possible combinations of symptoms that can meet DSM-5 criteria for MDD, and 2 different patients can be diagnosed with MDD without a single overlapping symptom. Continue Reading

Two additional diagnostic issues of import in contemporary psychiatry are the relationships of MDD to burnout and bereavement. About 40% of health care workers experience distressing symptoms of burnout, likely even more so since the start of the COVID-19 pandemic. As someone working in the physician wellness arena, I see many physicians complaining of burnout, some of whom come to me on previously prescribed antidepressant medications, which have essentially no positive effect on burnout, and others who present with significant underlying MDD that has been misattributed to burnout. Continue Reading

Despite many clinicians’ best efforts to select the antidepressant medication most likely to benefit their patient, many patients cannot tolerate a high enough dose to optimize benefits, and of those who do, only about half to two-thirds respond and only about a third achieve remission. Even among those who remit, relapse and recurrence are the norms, often within weeks to months after remission, and many more times over the life span. Continue Reading

The concept of treatment-resistant depression (TRD), based solely upon failure to achieve remission with 2 or more adequately delivered medication trials, may have outlived its usefulness. A broader, perhaps more empathic, concept of difficult to treat depression (DTD) has been proposed to replace TRD. DTD is defined as “depression that continues to cause significant burden despite usual treatment efforts.” Continue Reading

When I was in my training as a psychiatrist more than 50 years ago, we had tricyclic and monoamine oxidase inhibitor antidepressants, and we began the search for medications that were better tolerated, worked more quickly, were more effective for a broader range of patients, and had more sustainable effects. Although several new medications and classes of antidepressants have been developed in the ensuing decades, until very recently the search was focused exclusively on monoaminergic-based strategies. Continue Reading

An abundance of literature documents the superiority of antidepressant medication plus psychotherapy over medication alone for MDD. Yet, when it comes to training the next generation of psychiatrists, we are observing a monumental paradox. Since 2013, the Accreditation Council for Graduate Medical Education (ACGME) standards and requirements for psychotherapy training in psychiatric residencies call for developing competencies in the areas of cognitive-behavioral therapy (CBT), psychodynamic psychotherapy, and supportive psychotherapy in both brief and long-term formats, with optional experiences in group and couples/family therapy. Yet, currently, fewer psychiatrists than ever are providing psychotherapy to patients with MDD, or any diagnoses for that matter. Continue Reading

Physician distress is increasingly recognized as a professional and public health crisis. High rates of suffering including career dissatisfaction, secondary trauma or second victim phenomena (in psychiatry, often related to coping with patient suicide), burnout, substance abuse, depression, and suicide are all receiving national attention and calls for action. While there has been outpouring of attention to recognize and attenuate physician burnout, far less attention has been allocated to the recognition and treatment of MDD in physicians. Yet, perhaps the most actionable prevention strategy for suicide is prompt recognition in optimal treatment of MDD. Continue Reading

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