Treatment-Resistant Depression and Anxiety

Around 20–50% of people who complete psychotherapy in clinical trials do not get lasting benefit.[1] And outside clinical trials the failure rates are even higher. Depressions that have not responded to multiple therapies or medications are known as Treatment Resistant Depressions.

I specialize in Intensive Short-Term Dynamic Psychotherapy (ISTDP), one of the few treatments proven effective for Treatment Resistant Depression. In a recent study of people with Treatment Resistant Depression, 36% who received ISTDP had total remission of symptoms, and another 48% had partial remission.[2] This means that 84% of patients who had gotten little or no benefit in multiple prior treatments, experienced either full or partial remission.


By contrast, only 3.7% of patients who received “treatment as usual” (cognitive behavioral therapy or increase in medications) had a total remission, and only 18.5% had partial remission.


Does this mean that ISTDP works for everyone? Obviously not, since 16% of the patients in the study reported little or no benefit. No therapy will work for all people and all conditions. However, these findings show there is real hope for people whose depressions are longstanding and more complicated to treat. Importantly, treatment in the above study was relatively short-term, with an average of 16 therapy sessions. 

Continued —

More on ISTDP for Treatment-Resistant Depression 

Why are some depressions more resistant to treatment than others? Treatment resistance is usually related to personality factors, particularly how patients relate to others, such as the therapist.


Unlike strictly medical procedures, psychotherapy requires the patient to develop a working relationship of trust and mutual engagement with the therapist. This relationship, called the therapeutic alliance, is the bedrock of any successful therapy. Based on their own relationship experiences, patients bring to therapy many assumptions and tendencies — both conscious and unconscious — about relationships that can affect this working alliance.

ISTDP systematically addresses the many ways patients may resist forming a strong therapeutic alliance — ways that are as varied as people’s early experiences in relationships.


For example, people may come to therapy with a compliant or subservient approach. Or they may detach and avoid emotional connection. Others might become fearful and anxious at the prospect of forming a therapeutic relationship. Some people become hostile or combative, seeing the therapist as a threat in some way.


All of these relationship maneuvers are totally understandable considering how people have learned to adapt to past relationships, but can prevent them from achieving their goals in therapy. Therefore, in ISTDP we address these relationship factors actively — working through them is an essential part of the therapy. After all, the ways that people create, cut off, or limit relationships often contribute to depression in the first place.


Another unique way the ISTDP therapist works to maximize treatment success is by paying close attention to the body’s signals of feelings and anxiety. Working within an individual’s “window of tolerance” for anxiety is essential to a good therapy outcome. People whose anxiety is too high naturally withdraw from contact or quit therapy altogether. If you are prone to higher levels of anxiety we would probably spend more time practicing regulating your anxiety, particularly in the initial stages of therapy.


On the other hand, people who experience little or no anxiety often become stuck or discouraged in “talk therapies” because they can feel as if “nothing is happening.” And, in part, that is true. It is human nature to try to avoid anxiety, but doing so can make our lives feel flat and uninteresting, and our therapies ineffective.

When we avoid anxiety in therapy — for example, by talking about issues without feeling an emotional connection to them — therapy can grind to a halt. People who experienced this in prior therapies often report “we talked about a lot of things, and the therapist listened and made comments, but nothing changed.”

In ISTDP we will work together each session to develop a clear focus on your goals for the session, while closely monitoring your body’s experience of feelings and anxiety. This helps us stay in tune with what is emotionally relevant and important to you, to focus and maximize the precious time you spend in therapy. The more focused we can stay on the issues that have emotional value to you, the sooner you will see progress toward your goals.

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[1] Lambert, M.J. (2013). The efficacy and effectiveness of psychotherapy. In M.J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change  (169–208). Hoboken, NJ: Wiley.

[2] Town, J.M., Abbass, A., Stride, C., & Bernier, D. (2017). A randomized controlled trial of intensive short-term dynamic psychotherapy for treatment-resistant depression: The Halifax depression study. Journal of Affective Disorders, 214, 15–25.