The contested zone: interviews with GPs about their beliefs about treatment-resistant depression, 2023, Talbot et al

[Andy]

Abstract for a poster presentation made at the British Journal of General Practice.


Background
Treatment-resistant depression (TRD) is when antidepressants do not work and affects 55% of British primary care users with depression. People with TRD should be referred to secondary care but there are long wait times. This means most people are managed by GPs, but primary care guidelines are not standardised. Thus, how GPs manage people with TRD may vary, and there is limited evidence for how quality care may look. As a result of this variation, an investigation into how GPs manage people might be valuable.

Aim
To understand and interpret how GPs make decisions about treatment for people with potential TRD.

Method
Fourteen GPs were interviewed by AT, patient-led researcher with bipolar, and LH, a GP. Interviews started with a vignette where someone did not respond to antidepressants. We followed up with semi-structured questions. Data were transcribed verbatim and analysed thematically.

Results
GPs gave eleven explanations for antidepressant ineffectiveness before and instead of TRD. Explanations included misdiagnosis, medicalised misery, not yet found the right antidepressant, believing too much in antidepressants, and not engaging with psychological interventions. We interpreted that the prioritisation of these explanations suggests that TRD can be contested diagnosis. This interpretation was not only latent but overt in our data: ‘I think if we call things TRD, we undermine the impact of those other changes.’

Conclusion
TRD can be a contested diagnosis in the same way as ADHD, ME, and long-COVID. GP training and continuing professional development may support GP awareness of TRD and help them in confidently making the diagnosis.

https://bjgp.org/content/73/suppl_1/bjgp23X733929

 

[CRG]

1st author: Amelia Talbot

 

[Ash]

“ME” is it now? Interesting.

Contested. By some actor or other?
Might be relevant to patients, who’s doing the contesting mightn’t it?

Especially considering ‘CFS’ appears not “contested” by the right actors according these authors.

Personally I think this conclusion should be able to stand up on its own without throwing causal mention of separate conditions. If authors really want to bring in other conditions then I think there is an obligation upon them to explain right there why they feel the need to make such a comparisons.

 

[rvallee]

Treatment-resistant depression

This is such a meaningless term. The treatments are not effective. It is known that they are not effective. It is not the depression that resists treatment, it is the treatments that are not effective.

Medicine is badly in need of soft skills. And however soft psychological skills may be, they're clearly the wrong type, and too dogmatic anyway.

This interpretation was not only latent but overt in our data: ‘I think if we call things TRD, we undermine the impact of those other changes.’

It's good to see that those researchers have the right interpretation, but this did not happen by accident. There is ample blame to lay here, mostly at having massively oversold the effectiveness of treatments that barely work, if at all. This is clearly a generalized problem in healthcare, the need to stick to simple solutions to complex problems leading to falsely attributing blame to factors that are mostly, or entirely, irrelevant.

However, yet again the language of the conclusion keeps the idea of treatment-resistant depression over the simple reality that there is no effective treatment, no way to objectively diagnose, and even the definition has become so generic and superficial as to be completely meaningless. This is the harm that the biopsychosocial ideology has caused, continues to cause, and will continue to cause until people stop lying to themselves.

 

[Ash]

The treatments are not effective. It is known that they are not effective. It is not the depression that resists treatment, it is the treatments that are not effective.

Umm.

It’s like the terminology just somehow always falls butter side up for these researchers and company. While the dusty singed patient is carefully scrutinised and interrogated over why they just insist on playing a game that will inevitably leave them on the floor face first with someone’s expensive shoe on their neck.

However, yet again the language of the conclusion keeps the idea of treatment-resistant depression over the simple reality that there is no effective treatment, no way to objectively diagnose

 

[Hoopoe]

This is such a meaningless term. The treatments are not effective. It is known that they are not effective. It is not the depression that resists treatment, it is the treatments that are not effective.

Yes.

And I bet it's "contested" because the patients often rightfully want to explore other diagnoses and stop believing they have depression.

 

[Arnie Pye]

medicalised misery

I don't know what this means.

Is it implying that people whose life circumstances are poor and/or they live in misery won't benefit from treatment? I'm thinking of the homeless, the bereaved, the bullied, those in chronic pain or long-term sick, ...

 

[Trish]

Perhaps it is suggesting that if someone's depression is entirely caused by very difficult life circumstances, then giving them antidepressants or therapy isn't the solution. The solution is to provide them with decent housing, remove the bullies, treat the physical symptoms etc.

 

[Hutan]

Perhaps it is suggesting that if someone's depression is entirely caused by very difficult life circumstances, then giving them antidepressants or therapy isn't the solution. The solution is to provide them with decent housing, remove the bullies, treat the physical symptoms etc.

Yes. I think it's entirely reasonable for a GP to respond to the scenario of a patient who didn't respond to treatment with anti-depressant drugs by considering the possibility that the person might be sad, rather than medically ill. Considering the possibility that they might have been misdiagnosed and have some other condition also seems entirely reasonable.

That isn't contesting the diagnosis of treatment-resistant depression any more than saying 'someone who doesn't respond to an antibiotic might need to be evaluated for things that aren't bacterial infections' is contesting the existence of treatment-resistant bacterial infections.

I think this research adds a bit more confusion to a field that, as others have said, is already very confused.