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Treatment Resistance and Chronicity of Depression

TREATMENT RESISTANCE AND CHRONICITY OF DEPRESSION Dear Sir: MacEwan and Remick (1) have very lucidly described the challenging problems of Treatment Resistant Depression (TRD). In fact treatment resistant depressions are closely related to chronic depressions, and factors responsible for chronic and treatment resistant depressions are similar. Scott (2) has described a number of features and factors responsible for chronicity of depression. Though MacEwan and Remick have not discussed the significance of symptomatic profile in treatment resistance of depression I would like to emphasize the importance of certain symptoms. Presence of somatic symptoms like chronic pain are perhaps more frequent in those who develop chronic depression. Somatic symptoms are known to predominate minor (dysthymic) as well as major (also, melancholic) depression, and tend to be resistant to most interventions (3). An interesting type of double depression has also been identified which has predominantly somatic manifestation. In this disorder, acute and severe somatic symptoms are superimposed on an underlying chronic neurotic depression with predominant somatic presentation. The features of sadness, tearfulness and depressive thinking are conspicuous by their absence. There is thus a presentation of "masked double depression" or "double somatized depression" (4). The somatic symptoms exacerbate in episodes and again return to the premorbid somatic baseline. Such patients spend a lot of their time, energy, and money on general physicians who also find it extremely difficult to identify and treat the disorder. Many times such cases are likely to be considered as TRD. Second is the presentation of depression with features as anhedonia, amotivation, and associality (negative symptoms). These symptoms also predict chronicity and an unsatisfactory response to tricyclic antidepressants. Such anhedonic depressives require a much longer duration of treatment than the hedonic depressives despite which only partial or no recovery is achieved (5). Psychiatrists should be aware that besides the features described by MacEwan and Remick (l) and Scott (2) somatization and anhedonia may also be related to treatment resistance of depression.