Treatment Resistant Depression- case example and implications

The connotations of TRD are truly mind boggling when one takes a minute and thinks about it. Yes there is the TRD which is seen in some patients with maladaptive personality dynamics and then there is TRD which is people with good adaptive skills. On one side of the swing if there is no way to determine what another person is going through and there is no way of quantifying misery and depression then we are in the danger of not giving enough credence to a condition that we cannot imagine. Take the phenomenon of fibromyalgia. However there is the other side also to which the swing tends to go. Calling a mood state TRD medicalizes the whole interaction in to a disease like diabetes. Medicalizing the field of psychiatry which has its basis in biopsychosocial etiology risks neglecting the psychosocial aspects. Yes, a psychiatrist who is doing 15 minute medication check will definitely tend to benefit from it, as is illustrated in the following example but whatever semblance of a connection that is built in these visits will be on a faulty premise of being in cahoots with the patient's selective inattention (like Harry Stack Sullivan points out). The only playing field and the opportunity of intervention then left is in the same vein as the reason why such a restriction in physician patient interaction exists. It exists because there is a need for efficiency. It exists because of the devaluation of the physician patient interaction to the business model. A business model that take the same thing and repeats itself over and over again without having the ability in it for any play to cater for the uniqueness of the patient. Winnicott's rising to the challenge of the case is not killed only but defiled when using the term treatment resistant depression.
Here is a case example. Ofcourse a lot of the case is fictional but reflects actual clinical material garnered from actual patient interactions.

45 year old lady who was seen for the first visit for depression. She had already tried multiple medications before including ECTs and came in for an evaluation of TRD. Some other physician had been kind enough to give her the handle and an image of how to present herself to other physicians. She signaled challenge and she signalled hopelessness. She has been doing an excellent job at trying to do all the normal things that "normal people" do. She dresses well, she has the average life that an average doctor would have. She was the epitomy of average-ness. She has a job. She has everything that will NOT raise the flags to maladaptive personality dynamics. She is a seasoned patient who has learnt how to interact with the medical system and whether she knows it or not she is going to be very genuine in this role. I asked ofcourse for all the records in her case. In the next visit, I was dutifully given access to a huge file of all the treatments she had tried. I spent two hours on a weekend making a list of all the medication combinations she had been on and the time lines of various treatments by this excellent physician who had retired and had bequeathed this lady in my care. She started on antidepressants, ofcourse the SSRIs. She went through all of them without response to depressive symptoms and then she  went through the SNRIs and after that she turned to tricyclics and then various combinations including the california cocktail and then with all of them add in ECT and then along with ECT mood stabilizers and then atypicals and then two different times of taper of the medications and MAOIs. Then of course were the multiple dietary aids including fish oil, deplin, vitamin D. And to top it off there were analeptics and Modafinil and some talk about Cannibinoids which I do not think ever happened.
This was clearly a textbook of how psychiatry is practiced in 15 minute med checks. The things keep on increasing and increasing. This woman had seen the psychiatrist for 20 years. Either it was the connection to the psychiatrist or her protective factors that she was alive. She of course has always had a therapist and when I made contact with her, she talked about how much progress she had made in therapy over the years. The only progress I could see was that she had learnt the system and gotten used to her suffering identity.
I contemplated on what I was going to tell her in the next visit. Should I continue this game of changing medications. Would she come back if I told her that hope for a cure is impossible.
Anyways after one year of seeing her she has had one crises and I feel it was to test me, but she remains depressed and is still waiting for the magic cure. I continue covering the same grounds with her as before. She knows it but she also knows that this is the limitations of the system that is close ended. Lately I have been trying to steer her away from VNS and DBS but who knows maybe that is where things will go.
Here is when I ask myself if things could have been different when she was 25. Maybe, maybe not. I do not know and she does not know. I spend 15 minutes with her and she spends 15 minutes with me every 4 weeks and she is not content and I am not content. Would 45 minutes with her leave her more content and would it leave me more content or would it be the reverse.

As Pink Floyd says "running over the same old ground. What have we found? The same old fears."