The Failed Concept of Treatment Resistance

CONFERENCE REPORTER

According to some estimates, about 20% to 60% of psychiatric diagnoses eventually become labeled “treatment resistant,” yet psychiatry seems to lack a consensus on what “treatment resistance” means, including clear criteria, H. Paul Putman III, MD, told Psychiatric Times in an exclusive interview.

Putman, a Distinguished Life Fellow of the American Psychiatric Association and a Fellow and former Laughlin Fellow of the American College of Psychiatrists (ACP), led the session “Encountering Treatment Resistance and Finding Solutions” at the 2024 American Psychiatric Association Annual Meeting in New York City, May 3-8, 2024.1 In his presentation, he explored the concept of treatment resistance and how these cases may actually be a result of treatment failure. The goal, he noted, is to help patients, including those whose initial outcomes are disappointing.

Putnam said the field needs to shift its focus. Part of that, he told Psychiatric Times, is remembering that clinicians are humans who make mistakes. Before leveraging the term treatment resistant, Putnam, it is important to examine and rethink the facts. “We have innate biases that distort our clinical reasoning,” he explained. “We are not as aware of them all the time as we need to be, and I include myself.”

He explained clinicians need to use metacognition to avoid being on autopilot, which should result in less treatment failures for patients. Metacognition should help clinicians consider if the tools they are using as part of the treatment strategy are the most appropriate tools for each particular case. Similarly, it should allow clinicians to learn more tools and find new ways to apply those tools during diagnosis and treatment planning. Moreover, this approach encourages clinicians to go back and reexamine the problem from the beginning when there is a treatment failure, so they can better understand what data is missing and how to obtain that data. “This creative iteration needs to go on over and over again until you get satisfactory results for your patients,” he explained.

In addition to presenting this approach at the APA Annual Meeting, interested readers can learn more about Putnam’s philosophy and strategies in the book “Encountering Treatment Resistance

Solutions Through Reconceptualization.”

Reference

1. Encountering Treatment Resistance and Finding Solutions. Presented at the 2024 American Psychiatric Association Annual Meeting. New York City. May 3-8, 2024.

Further Reading

Demyttenaere K. What is treatment resistance in psychiatry? A “difficult to treat” concept. World Psychiatry. 2019;18(3):354–355.

Howes OD, Thase ME, Pillinger T. Treatment resistance in psychiatry: state of the art and new directions. Mol Psychiatry. 2022;27(1):58-72.

Markowitz JC, Wright JH, Peeters F, Thase ME, Kocsis JH, Sudak DM. The neglected role of psychotherapy for treatment-resistant depression. Am J Psychiatry. 2022;179(2):90-93.

Nasrallah H. From the editor: treatment resistance is a myth! Current Psychiatry. 2021;20(3):14–16.

Dr Putman is a Distinguished Life Fellow of the APA and Fellow of the American College of Psychiatrists, a practicing psychiatrist and mentor for over 30 years, and author of the book, Encountering Treatment Resistance: Solutions Through Reconceptualization and Rational Psychopharmacology: A Book of Clinical Skills.