4 Signs You Have “Treatment-Resistant” Depression
OR: Why I Put “Treatment-Resistant” in Quotes
- Medications have not resolved your difficulties—You have tried numerous medications. Dosages have been increased and decreased. Cocktails of medications have been created, including “off-label” usage of antipsychotics or stimulants. Despite the efforts of your psychopharmacologist, symptoms and interpersonal problems persist.
- Psychotherapy has produced marginal or no long-term improvement—Perhaps you have learned cognitive and behavioral strategies that produced positive benefits for a time. Then, suddenly, in the face of emotional stress, those strategies fail and your symptoms return. Perhaps you have been in a long-term insight-oriented therapy; you know yourself better intellectually, but your emotional symptoms persist.
- Somatic treatments are being recommended—Perhaps you and your doctors are considering Electroconvulsive Therapy (ECT), Transcranial Magnetic Stimulation (TMS), or Vagus Nerve Stimulation (VNS). You’re weighing the considerable risks and potential benefits of these procedures, and even considering the neurosurgery required for VNS.
- You are feeling hopeless about recovery—You’ve been trying to live your life dominated by symptoms, or at least you’re living in fear that they are lurking close by. You have put your faith in doctors and other helpers and have been let down. Multiple remissions and relapses have left you uncertain about your potential for recovery.
Sadly, “treatment resistance” in depression is all-too-common. One study found that only 50% of people treated at a specialty clinic achieved full remission of their symptoms (Petersen, et al., 2005), a finding echoed in a review of 25 clinical trials that found that more than half of the people treated with antidepressants remained symptomatic (Golden, et al., 2002). Even when some symptoms respond to treatments, many people continue to struggle with residual symptoms, and, even more concerning, residual symptoms are associated with increased risk of relapse (Paykel, et al., 1995). So, if this evidence makes a case for pessimism, then why am I so optimistic about the treatability of apparent “treatment resistance”?
I put “treatment resistance” in quotes because I believe that with the right therapeutic experience no emotional problem is truly intractable. Treatment resistance can often be an unfortunate side effect of the lack of knowledge and skill on the part of the clinician, rather than evidence of some deep and unmovable problem within you.
Now, I have yet to meet a therapist who wasn’t doing their absolute best (self included), but the unfortunate truth is that many of the medications and psychotherapy models that we learn to use in school today are but crude tools. Medication studies have shown only small evidence of efficacy for a limited range of people with depression (see Vohringer & Ghaemi, 2011 for a review and critique of this data). Follow-up studies of CBT have showed symptoms recur at follow-up, and even that CBT has become less effective over time (Johnsen & Friborg, 2015). How? Why?
My guess about why CBT is not showing the robust results that it once promised is that it attempts to gain conscious (READ: willful, intentional) control of unconscious (READ: automatic, unintentional) coping mechanisms that are often driven by unconscious forces—buried emotions and anxiety. When a low level of emotions and anxiety are stirred up, these conscious, intentional strategies can still work. However, coping strategies that work well at a low intensity of feelings can go offline at a higher intensity (e.g., in an interpersonal conflict), and unconscious, automatic modes of coping and unconsciously driven symptoms flood back in. This is then labeled as a relapse, or “treatment resistance”. This same problem can occur in psychoanalytic therapies that deal only with ideas and insights, not eliciting emotions and building capacity to feel and tolerate them.
So back to my optimism: The therapy that we practice, ISTDP, offers a systematic approach to embracing and understanding unconscious emotional factors (a.k.a. “building affect tolerance”) that drive symptoms like anxiety, detachment, catastrophization, negative self-talk, helplessness, hoplessness, and acting-out. Rather than helping you cope with only the thoughts, insights, and behaviors (still essential therapeutic ingredients), we can help you sort out the buried emotional engine(s) of these symptoms. This can produce massive symptom relief. Successful ISTDP treatment can help you develop the ability to become aware of and comfortable with your emotional reactions, even at high levels of emotional activation, which reduces the unconscious need for the mind to create the symptoms that hide them.
Now, is ISTDP perfect? Can it help everybody, every time? Certainly not, but there is reason to be optimistic. The research base of ISTDP is repeatedly demonstrating large and sustained effects, even for complex presenting problems (e.g., personality disorders, somatic symptoms, depression complicated by personality disorders; Abbass, 2015). This, in addition to my own experiences as a therapist working with treatment-resistant difficulties, drives my optimism. Most importantly for folks being encouraged to pursue ECT or other somatic interventions, use of ISTDP on an inpatient unit was associate with reduced usage of ECT (Abbass, et al., 2013). Click http://istdpinstitute.com/research/ for a very readable summary of the research on ISTDP.
Harry Stack Sullivan is credited with having said: “No one is schizophrenic when they’re talking to me.” In our practice, we aim to build a relationship with you in which you are free to be yourself without your depressive symptoms. We try to support you and help you find the inner power to overcome so-called “treatment resistance”. If you have been told your symptoms are treatment resistant, consider contacting us for a consultation, and we can make an effort to determine whether that is really the case. Ideally, no one is “treatment-resistant” when they’re talking to us.
Abbass, A. (2015). Reaching through resistance. Kansas City, MO: Seven Leaves Press
Golden, RN, Nemeroff CB, & McSorley (2002). Efficacy and tolerability of controlled-release and immediate-release paroxetine in the treatment of depression. J Clin Psychiatry, 63, 577–584
Johnsen, T., & Friborg, O. (2015). The Effects of Cognitive Behavioral Therapy as an Anti-Depressive Treatment is Falling: A Meta-Analysis. Psychological Bulletin DOI: 10.1037/bul0000015
Paykel, ES, Ramana, R, & Cooper, Z. (1995). Residual symptoms after partial remission: an important outcome in depression. Psychol Med, 25,1171–1180
Petersen, T., Papakostas, G.I., & Posternak, M.A. (2005). Empirical testing of two models for staging antidepressant treatment resistance. Journal of Clincal Psychopharmacology, 25, 336-341
Vohringer, P.A., & Ghaemi, S.N. (2011). Solving the antidepressant efficacy question? Effect sizes in major depressive disorder. Clin Ther, 33, B49-B61.