Difficult-To-Treat Depression

A Sheppard Pratt Educational Series

Managing depression in an outpatient setting is often very rewarding work. Guiding people through an episode of depression helps them regain their joy and purpose in life, and it can also lead them to a deepened and more aware sense of self. It can be disappointing, however, for the people who do not respond to traditional antidepressants or who have chronic, recurring depression.

At Sheppard Pratt, we understand that many healthcare professionals have not received the necessary training for this specific population. They may have had limited or no exposure to these patients during training. They may be early-career and have not yet built up the longitudinal experience that helps with assessing and managing these cases. They may not have access to mentorship or guidance from more senior healthcare professionals. Or, they may find that textbooks present more prototypical cases and provide little guidance on how to interview, assess, and counsel patients appropriately.

We pulled our experience treating difficult to treat depression at Sheppard Pratt and created a curriculum to address this gap. Our goal is to empower psychiatric professionals to work effectively with such patients and stop the cycle of disappointment and frustration for everyone involved.

This curriculum provides an effective framework for assessing and managing adults and transitional-age youth with difficult-to-treat depression (DTD) in an outpatient setting. And best of all, it’s on-demand, online, free to use, and fulfills continuing education credit requirements for physicians, nurses, and psychologists.

At the end of this curriculum, participants will be able to:

Describe the concept of difficult-to-treat depressive symptoms and what meaningful improvement looks like
Identify tailored interviewing techniques and screening tools that can be incorporated into routine assessment of patients with difficult-to-treat depressive symptoms
Identify and integrate into the case formulation the multiple biopsychosocial factors that can complicate and perpetuate depressive symptoms
Craft a comprehensive treatment plan that includes an appraisal of behavioral, psychopharmacological, psychotherapeutic, and interventional treatment options, along with appropriate psychoeducation

The curriculum is broken up into several modules. It is designed to be a self-study journey, with assessment of current practices, integration of new information from our experts, and practice with case examples. The modules are sequenced to build upon information learned in previous ones, so we recommend viewing them in order. There is also a series of related lectures from international experts listed for more learning.

Module 1: Introduction to Difficult-to-Treat Depression

This introductory module forms the foundation for your learning to assess and manage difficult-to-treat depression. The first part describes what depression is and specifically differentiates between the main uses of the word “depression”, which can refer to a symptom, a syndrome, or a diagnosis. The second part defines difficult-to-treat depression, explains why we prefer that concept instead of treatment-resistant depression, and describes the clinical characteristics of that population. The third part outlines the four-step approach to assessing patients with difficult-to-treat depression.

Accordingly, by the end of this introductory module, you will be able to:

Differentiate between depression as a symptom, syndrome, and diagnosis
Describe the clinical characteristics of difficult-to-treat depression
Summarize the four-step approach to difficult-to-treat depression
Reflect on ways to modify your own approach to a patient with difficult-to-treat depression

Module 2: A case of misdiagnosis

In this module, you will have the opportunity to assess a patient with suspected difficult-to-treat depression. The first part reinforces the foundational principles you learned in the introductory module: differentiating syndrome from diagnosis and recognizing suspected difficult-to-treat depression. The second part reviews the PRAT approach and then specifically focuses on how to evaluate the psychiatric diagnosis using a review of systems. The third part reviews the clinical features of bipolar disorder, which is an important diagnosis to consider in suspected difficult-to-treat depression.

Module 3: A case of treatment futility

In this module, you will assess a patient with major depressive disorder whose current depressive episode has not remitted despite multiple medication trials. The first part reviews the PRAT approach for suspected difficult-to-treat depression. The second describes the STAR*D trial and its implications for additional medication trials. The third part introduces neuromodulation as a treatment strategy, providing an overview of electroconvulsive therapy, transcranial magnetic stimulation, and vagus nerve stimulation.

At the end of this module, you will be able to:

Apply the PRAT approach to a case example
Summarize the implications of the STAR*D trial
Counsel patients about indications, risks, and benefits of electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and vagus nerve stimulation (VNS)

This curriculum was created by Elizabeth Ryznar, MD, MSc, and produced by Lisa Illum, MLIS, MEd, with input from Scott Aaronson, MD; Patricia Carlson, MD; Steven Rainone, CRNP; Monica Rettenmier, MD; and Kimberly Schwartz, RN.

The curriculum and the grand rounds series was supported by Grant Number 6H79FG000999-01M001 from SAMHSA. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of SAMHSA.

For more educational content, check out our other on-demand grand rounds lectures on difficult-to-treat depression.

Difficult-To-Treat Depression

Module 1: Introduction to Difficult-to-Treat Depression

Module 2: A case of misdiagnosis

Module 3: A case of treatment futility

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