Abstract
Though the term “treatment resistance” (TR) is increasingly applied in psychiatry, consensus regarding definition, criteria, and utility of the concept are missing, and treatments beyond pharmacological are seldom considered in diagnosis or staging methods. Resultingly, calculations of the incidence and prevalence of TR and meta-analysis of interventional strategies are not possible. Though treatment failures (TF) have always been noted, only recently has the focus shifted from the efficacy of treatments to the recalcitrance of a presumed disorder. Response, remission, and partial response must be clarified when considering TF, which should not be applied with diagnoses not currently treatable to remission.
Clinicians must not assume the TR concept matches a concrete reality; there are myriad causes of TF, each unlikely to be the same as many other cases. Copying the phrase “TR” from other professionals propagates a destructive meme that damages critical thinking. TF offers valuable data that must be appreciated and applied, altering our diagnostic and therapeutic hypotheses for each case. TF is an experience that must lead to greater knowledge and creative solutions, not TR, a dead-end pseudo diagnosis of questionable validity and no utility. Rather than oversimplifying our tasks, we must embrace inherent complexity and ambiguity in order to find answers in the granularity of each clinical situation.
Failures of response and remission are merely phases of treatment, and we must remain hopeful and optimistic, fully intending to persist until clinical outcomes improve – this is our responsibility to each therapeutic alliance. We make a conceptual error when we confuse TF with TR; reclassifying a diagnosis as TR represents a failure of clinical reasoning and judgment. As valid treatment options remain for 2/3 of cases described as TR, we must cease using this label and improve our problem-solving skills in order to discover and provide better clinical outcomes.
Keywords
Treatment resistance, Treatment failure, Treatment resistant depression, Treatment resistant schizophrenia, Clinical reasoning, Clinical judgement, Diagnosis, Misdiagnosis, Meme