Do some treatment options not work for those with major depressive disorder?

The idea of treatment resistant depression is a somewhat nebulous and vague notion. The very existence of treatment resistant mental health disorders is seen by some as contentious, and some argue that labelling them as such could be damaging. Non the less, many with long-term mental health issues experience just that. Now, a major ongoing international study has added some essential detail and evidence to the claim, finding that adding psychotherapy as a treatment to those already taking antidepressant medication, does not improve treatment outcomes.

Written by Bryony Porteous-Sebouhian

What is the current worldwide picture for people with a diagnosis of major depressive disorder?

Depression is one of the most commonly diagnosed mental health disorders internationally. In 2021 the World Health Organization (WHO) estimated that the number of people living with depression worldwide was around 280 million, which has since increased to 322 million during the start of this year. This number is also likely an underestimate due to the number of people who are living with depression without seeking help, treatment or a diagnosis.

This means that the number of people living with depression worldwide is equivalent to something like the populations of the UK, France, Spain, Italy and Germany combined.

When seeking treatment, most people experiencing depression or who already have a diagnosis of depression, access antidepressants as the first choice/option. This is often paired with or sometimes replaced by psychotherapy or Cognitive Behavioural Therapy (CBT).

However, WHO says around a third of those with severe or ‘major’ depression don’t respond successfully to the combination of medication and therapy, this group of the population is known as ‘treatment resistant’. There has been discussion over the past three years that an answer to this might lie in the use of psychedelic assisted therapy in order to increase what is known as ‘brain plasticity’.

There haven’t been many studies that clearly outline that the current mode of treatment doesn’t work at all for these patients though, leaving many to wonder the legitimacy of the claims around ‘treatment resistant’ disorders.

What new evidence does this international study bring?

This new study, presented at the European Congress of Psychiatry was reported on by Eurekalert! The study brought together the combined expertise of clinicians from Austria, Italy, Belgium, Germany, Greece, France, Israel and Switzerland. Across the eight countries, the study managed to review the experiences of 1279 severely depressed adult patients.

The patients involved in the study had all been receiving pharmacological treatment through antidepressant medication, while 31.2% of the patients also went on to receive psychotherapy as well as their antidepressant treatment. A further three quarters of those who received therapy also underwent CBT.

The study found some interesting details about the demographic who were simultaneously being treated through medication and therapy:

• they tended to be younger
• they were mostly higher educated
• more were employed
• they had a lower suicide risk than those exclusively being treated with medication
• most experienced an earlier onset of severe depression
• many experienced migraines and other physiological ailments such as asthma
• finally, they received lower daily doses of antidepressants than those taking antidepressants exclusively.

Researchers on the study used the Hamilton Rating Scale for Depression and the Montgomery and ?sberg Depression Rating Scale to measure the severity of depression in each patient.

The researchers found that the use of additional psychotherapy did not lead to better treatment outcomes.

Lead researcher on the study, Professor Siegfried Kasper MD from the Medical University of Vienna reflected on the two main learning points from their work:

“Firstly, if you have been treated with antidepressants, additional psychotherapy does not seem to give you better treatment outcomes, even though it may improve your subjective well-being. The second is that those patients suffering from severe depression and receiving additional psychotherapy had more favourable socio-demographic and clinical characteristics.”

The researchers conducted follow-up work with 292 depressed patients who were receiving CBT and compared them to 107 patients receiving other psychotherapeutic interventions such as psychoanalytic therapy or systemic psychotherapy. They found no apparent difference in outcomes in relation to type of therapeutic intervention.

Dr Livia De Picker from the University of Antwerp has commented on the research saying that the findings that indicate no “real life” added value van be attributed to psychotherapy as a treatment when a patient is already treated with antidepressants, “doesn’t necessarily mean that psychotherapy is not useful.”

However Dr De Picker did say that, “It is a clear sign that the way we are currently managing these depressed patients with psychotherapy is not effective and needs critical evaluation.”

As Dr De Picker suggests in her final comments reflecting on this new research, treatment for severe depression seems to have become stagnant, with too many people suffering with it without any real progress or change seen in their outcomes from treatment.

As we maneuver through the uncertain and new possible treatments for treatment resistant mental health disorders such as major depressive disorder, these findings appear to be the ammunition that practitioners and other researchers need in order to develop better and more successful options.?