The Difference Between Treatment-Resistant Depression and a Depressive Personality

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Treatment-resistant depression is generally defined as patients failing two antidepressant trials (Voineskos et al., 2020). Would readers be surprised that, chances are, other factors like personality and psychosocial stressors should be considered before making such a determination?

With the above in mind, even if someone has a family history of depression, biological intervention alone isn't likely going to change it if the activating issue isn't resolved. Medication also is no silver bullet for when what passes as depression is really someone's personality. People of course may experience superimposed depressive periods because of the issues their personality engenders. Medication alone, however, is akin to tossing water on a big fire whenever it's stoked by wind, but never extinguishing the foundational embers, allowing it to conflagrate each time it is windy.

The depressive personality

Imagine someone woeful, sees only the negative, is easily discouraged, lacks enthusiasm, and feels entirely inadequate. This is a depressive personality.

A depressive personality is not an affective condition, but rather an inter-relational style (Shedler, 2022). More simply speaking, it's a condition fueled by pervasive pessimism. Sufferers are not necessarily depressed, but their core schema, or how they view themselves and the world, is through a depressing lens. Theodore Millon (2011) quoted Emil Kraepalin's description from 1931:

[They] take everything hard...brooding was invented for them. As genuine pessimists they see the future dark and dangerous before them...Overestimating all difficulties they tend to underestimate themselves, to feel themselves insufficient and they lack self-confidence and security...

Nancy McWilliams noted (2013) they tend to be sad, but sadness is not synonymous with depression. Further, they can seem high-spirited and psychologically robust, said Dr. McWilliams, but in listening to them there is an inner melancholy. This is driven by "being agonizingly aware of every sin they ever committed, every kindness they have neglected to extend."

There is intense pessimism, seismic guilt, and sadness. Thus, at first glance, this could seem a dead ringer for a major depressive episode (MDE), for which intervention as usual follows. Unfortunately, depressive personality disorder was removed from the DSM after the third edition, for it was allegedly too confusing with dysthymia/persistent depressive disorder. Provided the DSM is the mainstream reference, unless one is interested in personality or psychoanalytic practice, it likely will not be on the clinician's mind as a potential reason someone's "depression" will not remit.

Differentiating depression from personality

Depressive episodes, with their dysphoria, lack of energy and negative thinking, tend to come and go. Even chronic depression, defined as two or more years of symptoms, includes a caveat that the person has never gone more than two months without symptoms. Thus, "chronic depression" can come and go.

With a little investigation, though, it could also be discovered that this woeful, pessimistic demeanor is how the person has always been. Others might describe them as even when functioning optimally there is a palpable negativity. It's as if they were handed $1 million they'd comment, "Do you realize the tax I'll have to pay on this?" and ask why they deserve it. It's quite likely that early life events imbued them guilt, like trying to get their own needs met from an ill caregiver. Perhaps the caregiver was ill with severe depression.

As noted in my previous post, a very depressed caregiver might model hopelessness and helplessness from the start, shaping the child's propensity for a pessimistic worldview. In turn, they don't develop confidence, because they never try anything, given they learned "what's the point?" In time, they are bitter and discontented with life, and towards others who do well. In an attempt to capture some self-esteem, they may turn their suffering into a badge. It's as if to say, "I've suffered more than you. I'm more resilient." Think of someone who one-ups your hardships, or keeps a running tally of problems, always ready to share them.

Considering this pattern is largely learned, medication can't unlearn it for them. Therefore, medication trials are likely to fail, unless they are experiencing a superimposed MDE. Even then, if medication works, it will probably just appear to dampen symptom acuity as they return to their baseline "depressed" appearance. Thus, it's easy to suggest their "depression" is treatment resistant. (For more tips to differentiate depressive personality from depressive episodes see my previous post.)

Case study

My interest in this personality stemmed from my first obvious encounter with it.

Marjorie (name changed), described a long history of off-and-on therapy for depression that never helped. Marjorie had an irritability about her, and often looked tired. She started each session with a new reservoir of complaints about everything from weather to how miserable the community center activities were. "The people there probably don't like me, anyway," she said. Marjorie didn't know why she bothered trying to do anything because everything gave rise to some new discontentment. Once, during the winter, an old acquaintance invited her to visit Florida. "I'm not going," Marjorie told me. "Why should I go there to have panic attacks when I can have them here?" she reasoned. "I'll just make them miserable."

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Any attempt to form an alliance was met with, "I don't know why I bother talking to a young squirt like you." It was as if I was the only person willing to hear her complain. "This is the most miserable patient I ever encountered," I said to myself. I felt I needed to take cover when she arrived, steer her from complaining the entire session, and provide something that would gain her faith in me.

When I called her psychiatrist, he said, "It's not you. I've known her 20 years and she's always depressed. It ebbs and flows. With every prescription, she says it's not going to work. You know the placebo effect? She has the 'nocebo' effect." The doctor continued, "She actually likes you because you listen to her and she hasn't burned you out yet. Her kids have put up with this forever."

I hung up, figuring she was just bitterly hopeless from being depressed her whole life. I continued to try and show her I wasn't giving up like she might be thinking I would because she is a fatally hopeless case in her mind. After a couple more sessions, she decided our meetings were just more proof of her incorrigibility, and discontinued.

Knowing what I do now, I wish I attempted to explore Marjorie's internal landscape. Letting her know I'd like to understand her misery, and thus her, would have allowed a cake-and-eat-it-too experience. She could be airing grievances but in a way I might be able to employ. I might have better modeled she is worth knowing, despite her disposition, gaining her faith in my genuineness by being interested in what others tell her to cut out. Once Marjorie allowed me to know her, this willingness to allow some vulnerability could have opened the door to her trusting more pointed intervention attempts.

Anyone with a patient like Marjorie might find it helpful to revisit depressive personality literature. Though it is no longer in the DSM, it has remained recognized as a condition that can be successfully worked with (e.g., Millon, 2011; McWilliams, 2013, Clark & Hilchey, 2015; Shedler, 2022).

Disclaimer: The material provided in this post is for informational purposes only and is not intended to diagnose, treat, or prevent any illness in readers or people they know. The information should not replace personalized care or intervention from an individual’s provider or formal supervision if you’re a practitioner or student.