Refractory or difficult-to-treat depression? Understand – 02/08/2023 – Mental Health

The International Congress of Psychiatry, which took place in July, in the United Kingdom, proposed a new term for resistant depression: “difficult to treat depression”.

This would be a first step for specialists to start approaching the disorder in a multifactorial way, explains Eduardo Szaniecki, a psychiatrist and psychotherapist specializing in children and adolescents, who works at the Tavistock Clinic in London.

“Semantically, the new terminology emphasizes a historical model that takes into account not only biomedical factors, but also emotional and social factors, which are very likely to be contributing to the predisposition, precipitation, and even perpetuation of the disorder,” Szaniecki writes. in an exclusive article for the Mental Health blog.

Treatment-resistant or difficult-to-treat depression?

By Eduardo Szaniecki*

A term commonly used in clinical practice refers to treatment-resistant depression. This condition is usually defined as the perpetuation of symptoms despite attempts at adequate doses and duration of more than one antidepressant (used sequentially or in combination). But this approach does not make it very clear who or what exactly is being resisted, and it does not take into account several subjective issues present in the practice of prescribing antidepressants, such as the doctor’s relationship with the patient.

At the RCPsych International Congress 2023, which took place from 10 to 13 July in Liverpool, UK, this view was slightly adjusted and the term “difficult to treat depression” was proposed. Treatment pathways with some interesting emerging results were also presented.

The main treatments for the condition still include associating one medication with another, such as the use of bupropion with aripiprazole (STAR*D study). Other investigations have included the use of Pramipexole (a dopaminergic commonly used for Parkinson’s disease), anti-inflammatories (based on findings associating severe symptoms of depression with elevated blood levels of C-reactive protein), probiotics alone, but especially when combined with antidepressant, ketamine or esketamine, and also psilocybin. Several of these treatment options are still being studied and are expensive.

Semantically, the new terminology emphasizes a historical model that takes into account not only biomedical factors, but also emotional and social ones, which are very likely to be contributing to the predisposition, precipitation, and even perpetuation of the disorder. This is important, as it approaches the situation in a more holistic way, closer to the patient’s clinical and personal reality, and helps to think about the possible reasons and/or obstacles that are making the problem difficult to treat at that moment.

This approach also emphasizes the role of possible comorbidities such as hypothyroidism, drug use and trauma. Finally, it also helps to think about this situation in a more chronic way and the adjustments to be made, as happens, for example, with rheumatoid arthritis and diabetes.

Although the number of teenagers with depression is increasing, fortunately resistant or difficult-to-treat depression is still much rarer than in adults. When I have treated adolescents in this situation, associated difficulties are clearly prevalent, such as anxiety and family problems, emphasizing not only the importance of dealing with each of them, but also of taking psychodynamic and/or psychosocial issues into account when prescribing, of providing attention towards the symptoms, and try to understand the possible emotional reasons behind a drug treatment that is not working.

*Eduardo Szaniecki is a doctor, psychiatrist and psychotherapist of children and adolescents in the department of children, young adults and families of the Tavistock and Portman Foundation, in the United Kingdom, a century-old clinic that is part of the British national health system (NHS). He did postgraduate work at Maudsley Hospital and a master’s degree at the University of London, where he studied infant mental health.

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