Difficult-to-treat depression: the role of contexts and comorbidities

In this review, we examine several special psychosocial contexts, including pregnancy and motherhood, that may seriously interfere with depressed patients' ability or willingness to engage and remain in treatment for their depression. We also explore the kinds of often-unrecognized subsyndromal comorbidities, such as panic-agoraphobic spectrum, that may complicate conventional treatments for depression or prevent depressed patients from remaining engaged long enough to fully benefit from treatment. We argue that psychotherapy can play a crucial role in addressing the special psychosocial contexts and the kinds of comorbidities experienced by the patient with difficult-to-treat depression. For difficult-to-treat depression during pregnancy and motherhood, preliminary data from several studies suggest that 8-24 sessions of weekly interpersonal psychotherapy (IPT), often followed by monthly maintenance IPT, is a promising long-term treatment for both middle- and low-income women. For difficult-to-treat depression with panic-agoraphobic subsyndromal features, preliminary results suggest that an integrated treatment approach, combining IPT for depression and cognitive-behavioral treatment for coexisting symptoms of panic, leads to higher depression response rates. These data imply that tailoring treatments to patients' specific needs and circumstances may be the real key to making depression less difficult to treat.