Expert Commentary

Collaborative Approaches to Treatment-Resistant Depression

Michael Robert Clark, MD, MPH, MBA, Joyce King MD, and Glenn J. Treisman, MD, PhD

Michael Robert Clark, MD, MPH, MBA
Associate Professor & Director, Chronic Pain Treatment Program
Department of Psychiatry & Behavioral Sciences
The Johns Hopkins Hospital
Baltimore, MD


Joyce King, MD
Chair, Patient Care Advisory Committee
Director, Inpatient Training for Family Practice Residents
Franklin Square Hospital
Baltimore, MD


Glenn J. Treisman, MD, PhD
Professor of Psychiatry and Behavioral Sciences and of Medicine
Director, AIDS Psychiatry Service
The Johns Hopkins University School of Medicine
Baltimore, MD

Collaboration between primary care physicians (PCPs) and psychiatrists can result in more successful approaches to treatment-resistant depression. Since many patients are intimidated by an initial psychotherapeutic consultation, a PCP will typically make the first diagnosis of depression and then prescribe the first round of treatments. A PCP may also be consulted first because many patients face insurance reimbursement issues when referred to a psychiatrist. Thus, a good working relationship between PCP and psychiatrist is beneficial. Patients will often feel more comfortable receiving psychotherapy and more willing to pay out of pocket for treatment when necessary.


The collaborative approach is also appropriate if treatment is unsuccessful. For example, if the patient does not respond to the initial round of treatment, the PCP will often seek further guidance from a psychiatrist. Typically, PCPs prescribe antidepressants based on dosing recommendations in the drug’s package insert. Often, the initial dosing prescribed by the drug’s administration protocols is too cautious to be effective, especially in the short-term. In such cases, consultation with a psychiatrist is particularly beneficial, as many psychiatrists recommend higher dosages. When working collaboratively, both PCPs and psychiatrists will mutually decide to augment antidepressants with another class of antidepressant or an anticonvulsant that can stabilize mood and reduce anxiety. Ultimately, the relationship works best when constant communication between PCPs and psychiatrists occurs for specific cases. This is a most essential aspect of collaborative care and frequently affords patients the most successful treatments possible.


  1. Menchetti M, Bortolotti B, Rucci P et al. Depression in primary care: interpersonal counseling vs selective serotonin reuptake inhibitors. The DEPICS Study. A multicenter randomized controlled trial. Rationale and design. BMC Psychiatric. 2010;10:97.
  2. Clemens NA. Psychotherapy and the perfect storm of change. J Psychiatr Pract. 2009;15(5):408-14.
  3. Saatcioglu O, Gumus S, Kamberyan K, Yanik M. Efficacy of high-dose aripiprazole for treatment-resistant schizoaffective disorder: a case report. Psychopharmacol Bull. 2010;43(4):70-2.
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