In a recent case report I published in Case Reports in Psychiatry, I described a paradigmatic example that, in my view, highlights the urgent need to rethink how we approach chronic depression in clinical settings. Too often, we remain anchored to standardised models that fail to reflect the complexity of real-life cases. What we need is a more dynamic and personalised strategy, one that evolves with the patient rather than rigidly following a protocol.
The concept of difficult to treat depression, or DTD, is often misunderstood. It is not the same as treatment resistant depression. While the latter is defined largely by pharmacological resistance, DTD takes a broader view. It refers to cases where the response to treatment is obstructed by a combination of factors, including clinical features, cognitive patterns, motivational barriers, social conditions, and systemic issues, even when there is no formal resistance to medication.
In this sense, DTD is not merely a label for failed medication trials. It is a valuable clinical framework that helps us identify patients whose depression is both persistent and deeply impairing in functional and psychological terms.
The patient I described was a 63-year-old woman who had lived with recurrent depression for many years. More recently, her condition had become chronic, significantly affecting her ability to function in professional, social, and personal domains. Despite receiving multiple pharmacological treatments, the benefits were always partial and short-lived. Psychotherapy had also been attempted but was discontinued early on due to low motivation and a fragile therapeutic relationship.
Through a careful and comprehensive assessment, it became clear that the challenges extended far beyond biology. We identified signs of subclinical cognitive difficulties, a passive approach to coping, marked social withdrawal, scepticism towards treatment, and traits suggestive of a borderline personality structure.
In response, we moved towards a more coordinated and layered form of care. Her medication was adjusted to include both an antidepressant and a mood stabiliser. Psychoeducation was provided to her and to her family. Crucially, we brought in local services to create a support network involving the Community Mental Health Centre, a social worker, and housing assistance.
After six months, there were signs of steady improvement. Although full remission had not been achieved, she was showing progress in mood, re-engaging with daily life, and recovering some of the functional capacities that had long been diminished.
This case reinforced something I believe strongly. The narrow framework often used to guide depression treatment is no longer sufficient. The idea that a patient must fail two medications before qualifying for further care is not only simplistic but potentially harmful. It places the treatment model above the individual and leaves little room for clinical nuance.
By identifying her as a patient with DTD early in the process, we were able to avoid repeating ineffective pharmacological steps. Instead, we turned our focus to the human being behind the diagnosis. We examined her personal circumstances, her expectations, her ability to engage with care, and her available support system. This shift allowed us to form a therapeutic alliance that was grounded in her reality. It aimed for functional recovery rather than a theoretical ideal of full symptom clearance.
We often speak about personalised medicine in psychiatry, yet the conversation is too often dominated by talk of genes and biomarkers. I believe personalisation must be understood more broadly. It should mean adapting care to the patient’s personal history, their cognitive resources, their hopes, their fears, and the context in which they live.
This kind of care values flexibility and rejects the idea that one size fits all. It demands that we attend not only to the disorder but also to the individual’s lived experience. It also encourages the integration of biological, psychological, and social perspectives in a way that feels coherent to both the clinician and the patient. Initiatives like Precision Psychiatry and the Research Domain Criteria framework reflect this direction, but much still needs to be done at the practical level.
Despite its increasing presence in academic discussion, DTD remains largely absent from everyday psychiatric practice. This is a missed opportunity. Wider recognition of this construct could allow us to identify those at risk of chronic illness much earlier, break the cycle of trial and error, and use healthcare systems more wisely.
This case was not just a publication. It was my attempt to demonstrate what it means to apply a more human and realistic lens to treatment. My hope is that it can play a small part in encouraging a broader cultural shift within mental health care.
The future of psychiatry must move away from rigid procedures and turn instead towards care that is truly person centred. DTD should never be seen as a sign of therapeutic defeat. It should be embraced as a clinical tool that helps us better understand the layered nature of psychiatric illness and respond with the compassion, nuance, and skill that each individual deserves.
Walter Paganin, PhD is a psychiatrist and researcher based in Rome. His work focuses on chronic mood disorders and the development of integrated, patient-centred treatment models.
