The Psych Writer on Major Depressive Disorder, Part Two – Treatment Resistant Depression

Welcome to part two of my series on Major Depressive Disorder (MDD). If you’re looking for the introduction to what MDD is all about, you can find that here.

Last week in part one, I wrote about writing a character with MDD, after detailing the symptoms for the disorder (link in the first paragraph). This week, I’m going to discuss Treatment Resistant Depression (TRD), which I still like to pronounce as ‘turd,” because it really is a turd. When you’re writing a character and would like them to have TRD, it’s important to understand what it is.

So rather than go on with a laundry list of how your character may be written, I’ll go through what TRD is and how it is treated. Then you can decide how your character will fit into it or not. Remember, you’re writing your character as a human being, so it’s okay if they deviate a bit. Humans are not their disorder, so neither are your characters.

TRD is defined as MDD that has not responded to a minimum of two antidepressants. Although some literature says only one, in most professional settings, two antidepressants are tried before determining whether  the depression is treatment resistant.

The difficulty lies in determining the threshold for TRD. There is complete remission and partial remission in symptoms, and there is also reduction in severity of depression. So determining what’s enough for the patient is what determines whether depression is treatment-resistant or not. Personally, I prefer elimination of symptoms, and if any are left, then that’s not good enough, so it’s time to try something else or add something to the treatment. But some people are okay with partial remission. It’s sometimes enough to have some relief over no relief, so best practice is to support the patient’s decision if they have good decision making skills.

When a person has TRD, there are things that they can try to get help. Usually treating TRD begins with an increase of dosage or switching medications. If that doesn’t help, then an add-on is usually used. For example, if the SSRI isn’t working, a combination of an SSRI and an NRI may be used.

Sometimes playing around with medications doesn’t help, though, and sometimes it does exactly what it’s supposed to do. But if it doesn’t work and the patient isn’t already in counseling, they can try a combination of medication and psychotherapy.

Other treatment avenues are Electroconvulsive therapy (ECT), Transcranial magnetic stimulation (TMS), and Vagus nerve stimulation (VNS). Most people cringe when they hear “ECT,” but that’s because they associate it with what they’ve seen in the movies and in old videos when the treatment was actually horrible. Now, the patient is given a sedative and most sleep through it. I’ve watched it done (on video rather than in vivo) and the experience was underwhelming. Of course, there are risks with ECT, including short-term memory loss, but for some patients it beats the hell out of MDD/TRD.

Now, finally, the numbers. This is something you may want to consider when creating a character. Around 10% to 30% of people have TRD, and that number varies on the spectrum of TRD (whether it’s full or partial remission, reduction in severity, etc.). So when you’re creating this character and you want to give them TRD, consider Special Snowflake Syndrome (SSS).While it’s recently been co-opted as a political inflammatory term, I refuse to use it in that manner. SSS means that your character has become a little too precious. If you give them TRD, make sure that they don’t come out corny and cliched, and actually make their suffering real rather than something they manage to brush off whenever it’s inconvenient to your plot.

If you came here looking for help with depression, please seek the help of a licensed professional in your area. Depression is a horrible, soul-sucking disorder that takes your life piece-by-piece. Don’t let it take control over you. Call for help. It’s out there.


There is little more horrific than what lies in our own imaginations. If you love reading about nightmare worlds and strange happenings, check out my author page. You can also follow me on Twitter or Facebook.

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