The contested zone: interviews with GPs about their beliefs about treatment-resistant depression

BACKGROUND: Treatment-resistant depression (TRD) is when antidepressants do not work and affects 55% of British primary care users with depression. People with TRD should be referred to secondary care but there are long wait times. This means most people are managed by GPs, but primary care guidelines are not standardised. Thus, how GPs manage people with TRD may vary, and there is limited evidence for how quality care may look. As a result of this variation, an investigation into how GPs manage people might be valuable. AIM: To understand and interpret how GPs make decisions about treatment for people with potential TRD. METHOD: Fourteen GPs were interviewed by AT, patient-led researcher with bipolar, and LH, a GP. Interviews started with a vignette where someone did not respond to antidepressants. We followed up with semi-structured questions. Data were transcribed verbatim and analysed thematically. RESULTS: GPs gave eleven explanations for antidepressant ineffectiveness before and instead of TRD. Explanations included misdiagnosis, medicalised misery, not yet found the right antidepressant, believing too much in antidepressants, and not engaging with psychological interventions. We interpreted that the prioritisation of these explanations suggests that TRD can be contested diagnosis. This interpretation was not only latent but overt in our data: 'I think if we call things TRD, we undermine the impact of those other changes.' CONCLUSION: TRD can be a contested diagnosis in the same way as ADHD, ME, and long-COVID. GP training and continuing professional development may support GP awareness of TRD and help them in confidently making the diagnosis.