Trial-and-Error Approaches for Treatment-resistant Depression

For some people, depression does not improve after multiple treatments. This trial-and-error approach can be exhausting. Perhaps you have considered options like transcranial magnetic stimulation (TMS), nasal sprays, infusions, or electroconvulsive therapy (ECT). Sometimes these alternatives can be enormously helpful, but other times the depression lingers.

Psychotherapy may be the missing component for "treatment-resistant depression" in some cases. While biologically-based treatments can be life-saving, they often fall short. They may improve your mood in the short term, but rarely provide a clear pathway toward lasting recovery or a roadmap for how to live your life.

Precision Psychotherapy: The Need to Address Anhedonia

Many existing treatments do a mediocre job of changing a core symptom of depression called "anhedonia." Anhedonia is the inability to experience joy or pleasure. It is thought to originate from the brain circuits responsible for motivation and feeling the excitement in our lives.

Not everyone with depression experiences anhedonia. When it takes hold, it can be a sign of a more serious depressive episode. Metaphorically, the color drains from your experiences—everything feels black and white. This can lead to a reinforcing behavioral cycle. When life no longer feels rewarding, your drive to strive starts to fade away. Then, you can fall out of practice creating space for happiness.

Even traditional psychotherapies often miss the mark on anhedonia. Typical "talk therapy" usually focuses on negative emotions (e.g., anger, distress, anxiety). However, patients with anhedonic depression can be left in the dark about what to do with their lingering sadness and lack of motivation.

Positive Affect Treatment (PAT)

There is an exciting resurgence in “behavioral activation” psychotherapies, which are focused less on changing negative emotions and more on cultivating joy. One of the most prominent examples is called Positive Affect Treatment (PAT).

PAT takes the mystery out of happiness. It gives people with depression a more practical and applied framework for the unique hurdles that come with anhedonia:

• It’s not about brute force behavior change: It’s more similar to rekindling a fire or tending a garden.

• It targets the "why" and “how”: PAT is a framework for addressing behavioral withdrawal using strategies for leveraging your limited time and energy.

• It builds lasting changes: Unlike medications, which often stop working when you stop taking them, PAT approaches can be used for the rest of your life.

What Targeting Anhedonia Looks Like

Anhedonia-focused psychotherapy isn't just venting about your week—it’s a structured process. If you are considering neurostimulation or infusion treatments for depression, you may also consider a "precision" trial of psychotherapy to target anhedonia. In my telehealth private practice, I focus on the following for patients with depression:

1. Specialized assessment: Measuring anhedonia separate from the other symptoms of depression to see if PAT is a good fit.

2. Targeted engagement: Moving beyond the "just do more activities" approach to behavioral activation. Empowering people with realistic techniques known to "jumpstart" the brain's pleasure centers.

3. Skill Acquisition: Fostering new mindsets. Teaching patients to gently and consistently cultivate joy with skills rather than waiting for joy to happen by accident.

Reclaim Your Life

You may not have to settle for a life in black and white. Whether as a standalone alternative or an add-on, positive affect treatment (PAT) may offer benefits for depression that medication or neurostimulation alone may not provide.

In my telehealth practice, I offer a number of evidence-based individual psychotherapy options including PAT. I also run a skills-based psychotherapy group called 'Rekindling Joy,' which is designed specifically to help people re-engage with the world when experiencing anhedonic depression.