Working with clients at the intersection of depression and personality dysfunction: Scientific and clinical findings regarding complex depression

The complexity of treatment-resistant depression: A data-driven approach

BACKGROUND

Recent systematic reviews highlight great variability in defining and assessing treatment-resistant depression (TRD). A key problem is that definitions are consensus rather than data-led. This study seeks to offer a comprehensive socio-demographic and clinical description of a relevant sample.

METHODS

As part of a pragmatic randomized controlled trial, patients (N = 129) were managed in primary care for persistent depression and diagnosed with TRD. Data included previous treatment attempts, characteristics of the depressive illness, functioning, quality of life, co-occurring problems including suicidality, psychiatric and personality disorders, physical health conditions, and adverse events.

RESULTS

Findings show a severe and chronic course of depression with a duration of illness of 25+ years. Overall, 82.9 % had at least one other psychiatric diagnosis and 82.2 % at least one personality disorder; 69.8 % had significant musculoskeletal, gastrointestinal, genitourinary, or cardiovascular and respiratory physical health problems. All but 14 had severe difficulties in social and occupational functioning and reported severely impaired quality of life. Suicidal ideation was high: 44.9 % had made at least one serious suicide attempt and several reported multiple attempts with 17.8 % reporting a suicide attempt during childhood or adolescence. Of the patients, 79.8 % reported at least one adverse childhood experience.

LIMITATIONS

Potential for recall bias, not examining possible interactions, and absence of a control group.

CONCLUSIONS

Our findings reveal a complex and multifaceted condition and call for an urgent reconceptualization of TRD, which encompasses many interdependent variables and experiences. Individuals with TRD may be at a serious disadvantage in terms of receiving adequate treatment.

Case formulation as a bridge between theory, clinical practice, and research: A commentary

This commentary section is based on a comparative analysis of the five articles and case examples presented in this special issue. The place of Case Formulation in the field of psychotherapy is conceptualized as a necessary bridge between diagnostic systems and clinical practice. The common aspects of the five approaches included in the issue, as well as of the cases to which they were applied, are discussed to explore their possible cross-theoretical nature, especially in psychotherapy with more severe cases. All the clients presented in this section have experienced traumas, which manifest themselves as difficulties in their interpersonal relationships. We discuss the value of Case Formulation in the context of clinical practice and research as well as the challenges of fostering the cross-theoretical approach of this tool.