Identifying 'paradigm failures' contributing to treatment-resistant depression

Background: 'Treatment resistant depression' is likely to emerge from a number of factors, including application of the wrong diagnostic and treatment models. Method: Current paradigms for managing both depression and treatment resistant depression are considered. We then examine the prevalence of a set of paradigm failures that appeared to contribute to treatment resistant depression in outpatients of a tertiary referral Mood Disorders Unit. Results: Six illustrative paradigm failures are described and their frequencies within the clinical sample reported. Identified paradigm failures were diagnosing and/or managing a non-melancholic condition as if it were melancholic depression, failure to diagnose and manage bipolar disorder, psychotic depression or melancholic depression, misdiagnosing secondary depression and failure to identify organic determinants. Conclusion: We suggest that the identification of such 'paradigm failures'-and of others that can be assumed to operate-has the potential to enrich the assessment and management of depressed patients, and reduce the prevalence of treatment resistance. (c) 2005 Elsevier B.V. All rights reserved.