Great thread. I didn't realize there were many people interested in using these older drugs. I always have them in mind when patients are not doing well on the usual meds. But here's my question for all of you who use TCAs, MAOIs, and even ECT - who are these treatment resistant depressed patients? In my experience 99% of the patients who fail the common meds have a comorbid condition, either substance abuse, a personality disorder, PTSD, or maybe a somatoform disorder or chronic pain. Rather than treatment failure, there's usually a misdiagnosis.
It's similar with OCD. I believe I have seen one - ONE - legitimate case of this disorder in my entire career to date. Yet I've probably seen hundreds of patients who have it listed in their chart. The ONE patient I ever saw who I really thought had it, I put him on clomipramine and he did amazingly, but then he had a syncopal episode that was initially thought to be secondary to an arrhythmia. I couldn't get a clear answer from cardiology about whether there was something to worry about or not, so I just stopped it. However I kind of regret that because I think we are overly conservative with TCAs, and it was really helping him.
He was the only patient I've ever seen who actually had irrational obsessions and unavoidable compulsions. Every single other person I've ever seen who claims to have OCD actually has either some garden variety anxiety disorder or OCPD. Depression obviously is not quite that rare, but treatment resistant major depressive disorder where there's not a comorbid condition has been rare in my experience. Is that just me??
I agree that the idea of TRD itself is overly reductionist and in practice ignores a lot of psychiatric comorbidity (see this all the time in our TRD clinic). Secondly, as Kendler says psychiatric nosology attempts to "carve nature at its joints," but for TRD do the joints even exist? I generally find operational criteria useful, but I find fallacy in attempting to define/categorize depression by treatment failure. Here is a recent editorial on the subject that attempts to use the STAR*D structure, but again, is this really defining a clinically useful entity?
Toward an Evidence-Based, Operational Definition of Treatment-Resistant Depression (one of the authors is one of my attendings, and I brought this up with him) Depression is such a complex, heterogeneous syndrome that a more person centered approach (however far away we may be from that notwithstanding; right now there are a few predictors for ECT and CYP pharmacogenetic testing) to difficult to treat cases.
I think the model works better for schizophrenia (assuming the diagnosis is correct)- patient fails D2 blocking antipsychotic adequately dosed for an adequate duration, then fails clozapine with adequate blood levels/time, then fails ECT augmentation, etc (you are SOL at this point but the good news is over time they pay less attention to positive symptoms and *might* be more receptive to cognitive enhancement therapy
OCD can be tricky. I actually find OCD to be under-diagnosed in my patients, and in my experience, I have made the diagnosis when 1) I think the established diagnosis is wrong or doesn't completely explain psychopathology and 2) OC symptoms better explain the patient's impairment. For example, I have a patient who was previously diagnosed as ASPD+cocaine (hasn't used in many years)+ marijuana "use disorders" (still smokes weed) and labeled as "unspecified depression", all of which are true (is baseline dysregulated, immature, etc), but she was very behaviorally underactivated and sat at home all day (MJ notwithstanding). When I asked her why she mentioned that she doesn't like taking public transportation because of thoughts of contamination (though described it in an ego dystonic, obsessional manner) and when I went through the YBOCS questionnaire this was chronic and pervasive. She actually responded somewhat well to SRI treatment.
Nevertheless, I have seen things mistakenly called OCD but usually in the context of untreated primary affective or psychotic pathologies (which the classic phenomenologists have long described as featuring prominent obsessions) that resolve when the primary mood/psychotic disorder is treated. I've also seen it mistaken for autistic rigidity (I think in DSM IV it was very difficult to make separate diagnoses for the two), though I've seen and have several patients who have both ASD and separate OCD.
Some of the experts (one of my attendings included) think OCPD and OCD are on the same spectrum with some work showing trait manifestations in childhood predict the development of actual OCD later on, yet others in the field debate this.
