What We Know and How We Think About Treatment Resistant Depression
The Austen Riggs Center has a long history of treating patients who have tried and failed to respond to previous treatment efforts. Early on, Riggs clinicians recognized the importance of so-called “treatment resistant” psychiatric disorders and their associated societal, financial and personal burdens – including death by suicide. Some of you may have participated in one of our annual workshops at the American Psychiatric Association, or through offerings of the American Psychological Association, American Psychoanalytic Association or Academy of Psychoanalysis and Dynamic Psychiatry, where, for over a decade we have shared our writing and our teaching about treatment resistance. As time has moved forward, we have witnessed psychiatry slowly joining this concern.
Our book, Treatment Resistance and Patient Authority: The Austen Riggs Reader (2011) was followed by two additional books on treatment resistance (Treatment resistant depression: A roadmap for effective care, edited by Greden, Riba, McInnis, and Management of Treatment-Resistant Major Psychiatric Disorders, edited by Nemeroff). Last month an important new study on the burden of treatment resistant depression was published in Psychiatric Services. "A review of the clinical, economic and societal burden of treatment resistant depression: 1996-2013" by the late David Mrazek and colleagues contributes important new information on the subject, while also illustrating the problem psychiatry struggles with around the phenomenon of treatment resistance. Mrazek and colleagues selected and reviewed 62 high quality studies of treatment resistant depression, involving 59,462 patients, from among 442 studies they initially identified. Among their findings:
- 12-20% of depressed patients develop treatment resistant depression
- Treatment resistant depression patients have only a 20% probability of achieving remission
- 17% attempted suicide
- The annual added societal cost of treatment resistant depression is between $29 and $48 billion dollars
- The total societal cost of depression is $188 billion, compared to $131 billion for cancer, and $178 billion for diabetes.
These are important, if worrisome, contributions that highlight the burden of depression and treatment resistant depression, and they are eye catching enough to have led Psychiatric News to do a story on the study this month. However, the study also illustrates the biological tunnel vision of psychiatry when it comes to depression and treatment resistant depression.
From its definition to the algorithms used for treatment, the assumption is that it is all about medications. Treatment resistant depression is defined as failing trials of medications, as if no other treatment is of any relevance. This stance ignores emerging evidence that psychosocial factors, like early adverse experiences (e.g., abuse, neglect, deprivation or loss) play an important role in causing depression and other disorders--and in increasing the likelihood that depression will be treatment resistant. There is also emerging evidence that psychotherapy may be a central part of treating depression, especially in those with early adverse experiences. Similarly, Mrazek and colleagues recognize that few of even the highest quality studies attended to the presence in patients of comorbid diagnoses like borderline personality disorder (BPD), which has been found to robustly predict the persistence of major depression despite treatment. As the American Psychiatric Association practice guidelines note, optimal treatment for borderline personality disorder is psychotherapy. Yet failure even to look for BPD means you won't find it when you study treatment resistant depression, and thus won't treat it. This is a genuine blind spot of the field that suggests that the "resistance" in treatment resistant depression is not located in the patient, but in our field's biological tunnel vision that fails to include a psychosocial dimension in how we think about, study and treat disorders.