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.

The Psych Writer: Introducing Depression

This is part of a series of The Psych Writer. I tend to write about pretty heavy topics because they’re mainly about mental illness, and though there are many things we can laugh and joke about to alleviate pain, these topics can be painful for some. So I ask you to stay with me and be tough. Put on your writer’s cap and use one of my favorite defense mechanisms–intellectualize with me.

And now, for a disclaimer: None of this is a substitute for professional medical advice. This is for the sole purpose of writing a character with realistic tones. Of course, there’s always poetic license. If you have Major Depressive Disorder (MDD), note your individual experience may vary. If you see yourself in anything I’m describing, consult with a licensed clinician in your area for help.

This is only an introduction. MDD is a complex mood disorder with several possible complications and offshoots, so in order to keep your eyes from falling out of your head (disclaimer: not responsible for deleterious effects), I am going to have to break it up into parts other than this introduction.

So for now, let’s just get to know what MDD is all about. MDD has a lengthy symptom list. The DSM-5 lists MDD as a mood disorder. I’m going to attempt to put it all into plain English here for you, using the copy I have at home.

Here are the criteria for diagnosing Major Depressive disorder:

  • The symptoms must be present daily or nearly every day for a minimum of two weeks before a diagnosis can be made. That means it’s persistent and pervasive.
  • The symptoms must be a change from how the person functioned previously.
  • Five or more of the symptoms must be present during that two-week minimum period. On top of that, the person must have either a depressed mood (feelings of emptiness, sadness, irritability) or loss of interest and pleasure (aka anhedonia). They can have both, but at least one of these must be consistently present.
  • You’re not allowed to include symptoms that can belong to other medical conditions. In other words, they want you to make sure it’s not something else before treatment. Other physical conditions to rule out include:
    • Central nervous system diseases (e.g., Parkinson disease, dementia, multiple sclerosis, neoplastic lesions)
    • Endocrine disorders (e.g., hyperthyroidism, hypothyroidism)
    • Drug-related conditions (e.g., cocaine abuse, side effects of some CNS depressants)
    • Infectious disease (e.g., mononucleosis)
    • Sleep-related disorders
    • Adjustment Disorders
    • Anemia
    • Chronic Fatigue Syndrome
    • Dissociative Disorders
    • Hypochondriasis
    • Hypoglycemia
    • Hypopituitarism (Panhypopituitarism)

    Other psychological conditions to rule out include:

    • Dysthymia
    • Bipolar Disorder
    • Anxiety Disorders (e.g, PTSD, OCD, GAD)
    • Eating Disorders
    • Personality Disorders
    • Schizoaffective Disorder
    • Schizophrenia
    • Somatic Symptom Disorders

      ET CETERA

Okay, so now, the clinician gets into the symptoms. Symptoms of MDD (remember, there is a minimum of five with depressed mood and/or anhedonia being one of them) include:

  • Depressed mood most of the day, nearly every day for at least two weeks. The person can report this themselves (“I feel sad,” “I feel empty,” or “I feel hopeless), or it can be observed by others (“Patient appears tearful.”). For kids and teenagers, there is often a sharp increase in irritability, although irritability is sometimes seen in adults with depression, too. It’s just more often seen in the young ones.
  • Noticeably losing interest and/or pleasure in all or almost all activities that the person enjoyed before. This can be self-reported or by observation from someone else.
  • Significant weight loss when not dieting or weight gain–within one month, losing or gaining more than 5% of the person’s starting weight–or, an increase or decrease in appetite nearly every day (e.g., the person who used to eat their three square can barely choke down a bowl of pudding every day, or a person who used to eat lightly now eats constantly. In kids, this will be seen as failure to make their expected weight gain.
  • Not sleeping (insomnia) or sleeping too much (hypersomnia) almost every day.
  • Moving around too much (fidgeting) or not moving around enough (lethargy) nearly every day. This criterion is known as psychomotor agitation or psychomotor retardation. It also cannot be self-report alone–this must be observable by others.
  • Lack of energy nearly every day (fatigue). Can be self-reported or observed.
  • Feeling worthless or guilty inappropriately, sometimes to the point of being delusional. This isn’t just basic self-reproach or feeling guilt about an illness. It’s a magnified feeling.
  • Difficulty concentrating or making decisions nearly every day. This can be self-reported or observed.
  • Thoughts of death repeatedly–not just fear of death, suicidal thoughts without a plan, with a plan, or an attempt to commit suicide. This also includes repeated suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

And finally, the criteria for these symptoms has to fit as below:

  • The symptoms cause significant distress or inability to function in social situations, on the job, or anywhere a person needs to function.
  • The episode isn’t because of any of the conditions listed previously or because of drugs.
  • The depression isn’t better explained by another psychological condition as listed above.
  • The depression didn’t come with any mania or hypomania. Clinicians can’t count this exclusion if the mania/hypomania is due to a drug/substance or because of a medical condition.

Did you think that MDD was easy to diagnose? As you can see from above, it’s not always clear-cut. That’s why it’s important to pay attention to symptoms.

Keep all this in mind as we venture into the depths of writing MDD, and again, if you need help, contact a licensed clinician in your area for help.


I am a former supervised therapist with experience in the mental health field since I began graduate schooling in 2003. Now, I write about the things in my head.