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 an exhausting process. As a patient, you may receive several combinations of medications—switching from one drug to the next—only to find that meaningful improvement remains out of reach. As a result, patients can get labeled as having “treatment-resistant” depression.

Like many people with depression, perhaps you have considered some of the biologically based alternatives 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. Throughout this trial-and-error process, a vital question is often not discussed with patients: Have you actually had a proper trial of psychotherapy designed specifically for your symptoms?

Psychotherapy may be the missing component for treatment-resistant depression in some cases. Many problems you face may not be fixable by changing brain chemicals alone. While biologically based treatments can be life-saving, they often fall short. They may improve treatment-resistant depression in the short term, but rarely provide a clear pathway toward lasting recovery or a new roadmap for how to live life.

Precision Psychotherapy: The Need to Address Anhedonia

Many existing treatments do a mediocre job at helping people change a core symptom of depression called anhedonia. Anhedonia is the inability to experience joy or pleasure, which can occur among people with depression and other psychiatric disorders. It is thought to originate from the brain circuits critical for helping motivate us to pursue pleasure and reward in our lives.

Not everyone with depression experiences anhedonia. But when it takes hold, it can be a sign of a more serious depression. The world begins to lose its spark of excitement. Metaphorically, the color drains from your experiences—everything feels black and white. This isn't only a mood state; it's a reinforcing behavioral cycle. When life no longer feels rewarding, your drive to strive starts to fade away. People then fall out of practice creating space for happiness, which fuels a defeatist mentality.

Even traditional psychotherapies often miss the mark on anhedonia. General "talk therapy" and standard cognitive behavioral therapies (CBT) usually focus on negative emotions (e.g., anger, distress, anxiety) and the thought patterns driving those emotions. 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 thoughts and more on cultivating joy and pleasure. One of the most prominent examples is called Positive Affect Treatment (PAT).

PAT takes the mystery out of happiness. Researchers have known for a long time that encouraging people to do rewarding activities can combat depression. But older approaches often relied on an invalidating "just do it" message. People with depression need a more practical and applied framework to help with the unique hurdles that come with depression. PAT works differently:

• 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 understanding behavioral withdrawal paired with strategies for leveraging your limited time/energy when feeling depressed.

• 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

A "proper trial" of anhedonia-focused psychotherapy isn't just venting about your week. It’s a structured, evidence-based process. If you are considering alternative neurostimulation or infusion treatments for depression, you may want to also consider adding on a "precision" trial of psychotherapy to target anhedonia using the PAT approach. In my telehealth private practice, I focus on the following elements for patients with depression:

1. Specialized assessment: Measuring anhedonia in a targeted way 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. 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 don’t 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.

Assessment helps to pair people with treatments that make the most sense for their symptoms. In my telehealth practice based in Saint Paul, Minnesota, I specialize in this precision-style approach. In support of this, 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.