The Failed Concept of Treatment Resistance

The use of the term "treatment resistance" (TR) in psychiatry has blossomed over the last two decades, with 20%-60% of all cases now labeled as such. Remaining effective treatment options, however, can be identified for two-thirds of these cases. There is no consensus on definition or criteria for TR within any diagnostic category, and literature review supports a broad range of individual causes of treatment failure (TF), rather than an actual entity of TR. Application of the TR label inhibits a practitioner's search for the true cause(s) of TF, a disservice to the trust patients place in us and their hope for recovery. It also threatens to worsen prognosis by unnecessarily extending the length of an index or recurrent episode, and increases the risk of death and burden of disease by prolonging categorical and functional impairments. We must view TF as a stage of treatment, still expecting and seeking eventual remission, rather than applying TR as an endpoint and an unsanctioned pseudo diagnosis. We must always recall that the clinical tasks we face are inherently complex; routine solutions are unlikely to fit and often lead to TF. The actual value we offer our patients is our problem-solving skill and our willingness to be with them through the difficulties of reaching their goals. We can address so-called TR, or, rather, TF by confirming our diagnostic validity and accuracy, the thoroughness of our evaluations and monitoring efforts, the clarity of our therapeutic guidance, and the quality of our therapeutic alliances.