This is a very-well written article but its premise, to me it is a fallacy. I have never encounter one case of so-called TRD that does not respond to a trial with a mood stabilizer.
If we believe that depression is associated with certain receptors in the brain, it should not be a matter of discussion that when you have targeted all of them the mood should improve. On the other hand, almost 100% of patients that have come to me with “depression and anxiety” have a mood disorder and agitation, which is worsened using SSRIs (check the “ARAD” syndrome described by Dr. Ronald Pies).
This paper’s case vignette reminded me of a study published by a group in Canada that reported (in 2000) improvement of Conduct Disorder and Oppositional-Defiant Disorder with risperidone. Like in this case, patients improved because risperidone can help to balance the mood in patients with sub-threshold cases of bipolar spectrum disorder.
If clinicians continue to believe that “bipolar” is just what Kraepelin described (hundreds of years ago) we will keep seeing “Treatment-Resistant Depression”. Also, responsible for the failure to capture mild cases of the bipolar spectrum is the unjustifiable neglect of entering the family history into the equation to formulate a diagnosis. In gathering family history, we must be a “detective” and decline to be satisfied with “nobody in family has mental illness”. Many people use alcohol and cannabis (or worst yet, opioids) to control a “racing mind”, impulsivity or explosive temper.
Finally, one major obstacle in making a proper diagnosis of a bipolar spectrum disorder is the fear of “giving a bad label”, that some clinicians have. And this is puzzling to me because I see doctors telling the mother of a young child “your son has a malignant brain cancer” or to the wife of a man in his 40s, “your husband has a Stage-4 pancreatic cancer” while doctors and others in the mental health field hesitate to talk about a treatable illness.
Dr. Manuel Mota-Castillo
Chief of Psychiatry and Training Director at
Burrell College of Osteopathic Medicine (BCOM) and