Although there has been a substantial increase in awareness—and, I hope, understanding—of depression, there has been far less public discussion of the challenges that clinicians face in the management of this condition and of the challenges that many patients face getting better.
The public are increasingly aware that there are a range of antidepressant medications, and that some of these have problematic adverse effects. However, there has been far less public discussion about the frequent problems of therapeutic nonresponse and how we go about addressing these from a clinical perspective.
I wrote Curing Stubborn Depression: Emerging & Breakthrough Therapies for Treatment-Resistant Depression1 to try to help fill this information gap. The book is aimed at patients, interested members of the general public, and potentially non-psychiatry clinicians (other doctors and health workers) interested in the management of patients with mood disorders.
The book aims to make clear that response to antidepressant treatments, be they pharmaceutical or psychological, is not always simple, straightforward, or immediate: and that many patients will struggle to get better with standard treatments. But the book also emphasizes that the story is not all negative. There are a range of existing and emerging therapies that offer hope to many of these patients for improved treatment outcomes.
The book begins with an overview of depression and a description of the standard pharmaceutical and psychotherapeutic approaches that are most commonly used in its management. It then continues with a chapter exploring what should be considered when initial therapy is not working; how the diagnosis and potential presence of comorbidity should be thought about and addressed; and what second-, third-, and fourth-line pharmacotherapy options tend to look like. This includes a discussion about treatment doses, augmentation, and other strategies.
The book then addresses a range of lesser-known but increasingly important and prominent therapies. Chapters address the use of electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation, bright light therapy, deep brain stimulation, ketamine, and the emerging field of psychedelic-assisted psychotherapy.
Across these chapters, brief clinical vignettes are used to highlight important aspects of the treatments or areas of research being discussed. These are taken directly from my clinical experience over the years, managing patients with these modalities in clinical practice and in research trials.
The history and context of the therapeutic area under discussion are addressed in each chapter, along with some of the controversies and challenges that have emerged over time. There is an intent that some of these chapters will open the eyes of patients to the availability, efficacy, and tolerability of novel treatments such as rTMS, which are underused in certain areas of clinical practice.
The book ends with a series of practical suggestions for patients beginning, or who have already embarked on, the journey of treatment for depression. It includes what these patients should expect when being assessed, what to anticipate when commencing treatment, and the sorts of important questions to explore with their treating clinicians.
The book aims to help them become actively engaged in their treatment, to understand what is being proposed, and to understand this, as well as the alternatives, in a way that allows them to make meaningfully considered decisions. As such, I am hoping to make our patients more genuine participants and drivers of their care—to be able to work with their treating clinicians in an informed and up-to-date manner.
In particular, I hope the book encourages individuals with depression to “set the bar high” in regard to their treatment and recovery. Ultimately, the goal of treatment should be not just an improvement in symptoms but meaningful wellness. The pathway to this end may be a challenging one, but it is possible for many—if not most—individuals to get there. If these individuals are stuck in treatment (if, for example, they have been taking a medication for some time without optimal response), they should advocate for change and should have an expectation of fully engaged and proactive therapy.
I wrote this book because of the patients who have been coming to me for help for many years. Because of the patients who have been treated with 3 or 4 selective serotonin reuptake inhibitors (SSRIs) in a row, but nothing else. Because of those who were prescribed a single antidepressant that was not working for months, if not years, at a time. Because of those who spent many hours in psychotherapy, but probably only received some form of supportive counseling despite the fact that they continued to suffer the travails of their condition. Because of those who had been told that “rTMS is a sham” or that “all ECT will do is cause brain damage.”
There are many fantastic doctors and therapists out there helping patients with depression who provide excellent all-around care. However, there are also some who remain quite conservative and limited in their scope of practice, who predominantly practice psychopharmacology or psychotherapy, and who are not willing or able to recommend or discuss other treatment options.
All patients with depression deserve to understand all of their treatment options and to be able to weigh how these options may or may not be relevant to them. These patients also deserve some sense of hope for the future, and I hope Curing Stubborn Depression can provide some of both to them.