Patient and provider perspectives on the phenomenon and effective treatment of treatment-resistant depression: A grounded theory

Treatment-Resistant Depression (TRD) is a poorly understood but prevalent clinical phenomenon that lacks a widely accepted definition, explanatory model, or set of practice recommendations. It involves a chronic form of unipolar Major Depressive Disorder (MDD) that fails to respond to at least two first-line clinical treatments. TRD affects as many as 70% of patients who fail to respond to their first trial of antidepressant medication and 60% of patients who fail to respond to their first phase of psychotherapy. This qualitative study aims to develop a model for understanding the phenomenon of unipolar TRD and the practices involved in its effective treatment. This study involved a grounded theory analysis of interviews with four adult-American patients with unipolar TRD and five American providers who routinely treat such patients. A model of unipolar TRD was developed, explaining common etiological and maintaining factors of unipolar TRD and offering recommendations for guiding effective treatment. This study had a small sample size (N = 9) with limited sociodemographic diversity (all Americans; only two females; one racial/ethnic minority; no sexual minorities), which may limit its generalizability. Nevertheless, its emergent theory underscores the importance of TRD patients cultivating positive views of medication and psychotherapy while collaborating with their providers to obtain psychoeducation, build mindfulness/coping skills, enhance social support, and re-engage with pleasurable activities. It recommends that mental health providers focus on processing TRD patients' subjective experiences, validating patients' frustrations, and monitoring and calibrating patients' expectations.