Exploring Innovative Therapies for Treatment-Resistant Psychiatric Disorders (Podcast)

An estimated 30% to 50% of patients with psychiatric disorders struggle with treatment resistance – a complication that can lead to higher healthcare costs, unemployment and reduced productivity. Despite the prevalence of treatment resistance, however, fewer than 1% of psychiatric studies are focused on the problem.

“According to the Diagnostic and Statistical Manual of Mental Disorders, major depressive disorder alone can be diagnosed by the presence of more than 200 unique combinations of symptoms,” explains interventional neuropsychiatrist Stephen Ferber, MD, Assistant Director of Cleveland Clinic’s Psychiatric Treatment-Resistance Program. “That heterogeneity really impedes our ability to provide custom-tailored therapies, so we’ve been resigned to managing all those distinct symptoms – and the underlying neurobiological abnormalities that cause them – the same way. Psychiatry is a nonspecific field, but that's not where we need to be.”

In the latest episode of Cleveland Clinic’s Neuro Pathways podcast, Dr. Ferber shares practical insights for diagnosing and managing treatment-resistant mental health disorders. He discusses:

• The selection, administration and effectiveness of common psychiatric medications
• Targeted, symptom-based approaches like transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT)
• Potential applications for psychedelics, including psilocybin and LSD
• The importance of dedicated research programs to improve patient outcomes
• Predicting remission rates

Click the podcast player above to listen to the 20-minute episode now, or read on for a short, edited excerpt. Check out more Neuro Pathways episodes at clevelandclinic.org/neuropodcast or wherever you get your podcasts.

This activity has been approved for AMA PRA Category 1 Credit™ and ANCC contact hours. After listening to the podcast, you can claim your credit here.

Podcast excerpt

Podcast host Glen Stevens, DO, PhD: Let’s say your patient has treatment-resistant depression and you've [already trialed] two adequate medications. You know the patient has been compliant, but their symptoms are not improving. Do you go to a third [drug], or is it time to try a nonpharmacological intervention?

Dr. Ferber: What I would love to be able to do – but what we're unable to do, unfortunately – is to take that patient, look at their individual symptom profile, neuroimaging results, or biomarkers, and say, "Based on your specific cluster of symptoms, we know that you're going to have a higher chance of achieving remission with intervention X." Right now, treatment is much less specific than that.

I have a bit of an anti-medication bias, simply because global remission rates [show that] pharmacological options [are less effective] than any of the other interventional therapies. The reason we don't offer [alternative treatments] to patients right out of the gate is mainly because of insurance restrictions.

If I had depression, would I want to take fluoxetine for the rest of my life, or try a short course of TMS? The answer is easy from my perspective – but unfortunately, insurance [won’t typically cover TMS] until we've tried two, three or four medications.

ECT is the gold standard for managing treatment-resistant depression, but it obviously comes with a fairly significant side effect burden… and a huge stigma. It’s portrayed in the media in the worst way possible…. It’s made to look like torture. But [ECT has become] a necessary tool for psychiatrists, especially when managing individuals who just don't respond to these other options.