Do Therapeutic Models Need Improvement?

Sources:

Treatment Resistance & Diagnostic Critique McIntyre et al. — Treatment-resistant depression: definition, prevalence, detection, management — World Psychiatry (2023) Karabulut & Düzgün — Treatment-Resistant Depression Rates: Pilot data from Türkiye — PMC (2025) Treatment-resistant depression: a problematic illness or a problem in our approach? — British Journal of Psychiatry, Cambridge Core. Paganin — Treatment-resistant depression: time to rethink current definitions and clinical practice — Frontiers in Psychiatry (January 2026) Parker — A critique of ICD-11 criteria for the mood disorders — PMC (July 2025) Access, Structure & Policy European Psychiatric Association — Action Plan 2025-2027: Leaving No One Behind — PMC (2025) WHO — A new roadmap for mental health policy reform — PMC (October 2025) The Marburg Declaration — The future of psychological treatments — ScienceDirect (2024) Delgadillo et al. — Stratified care vs stepped care for depression: a cluster-randomised clinical trial — JAMA Psychiatry (2022) Precision & Personalised Psychiatry Restoring the missing person to personalized medicine and precision psychiatry — PMC (2023) Psychiatry Redefined — The Tipping Point for Functional Psychiatry on the Road to 2026 (2026) APA Monitor — The promise of precise, personalized mental health care (September 2025) Kas et al. — Precision psychiatry roadmap: towards a biology-informed framework — Molecular Psychiatry (August 2025) Crisis Resources — Include in Every Episode Description: Call or text 988 — Suicide and Crisis Lifeline (24/7, free, confidential) Text HOME to 741741 — Crisis Text Line (24/7, free, confidential). Not Fixed, Still Here · Episode 5.

Transcript

Copy Transcript Copied

SPEAKER_00 0:03

There is a phrase used in psychiatry that I won't start with today. Treatment resistant. It gets applied to people who have tried the standard treatment and not improved. And it sounds on the surface like a neutral clinical description. But sit with it for a moment. Treatment resistant places the resistance in the person. It does not ask whether the treatment was resistant to fitting them. We are going to ask the question that has been quietly running underneath everything else we've covered so far. Are the systems built to help us actually build around the reality of our experience? Welcome back to Not Fixed, Still Here, the podcast about mental health grounded in a science escaped by lived experience. I'm Torrin, not a therapist, not a clinician, someone who has spent 20 years inside these questions, and this is what happens when I ask them out loud. This is episode 5. We've covered the statistics of abuse, the origins and limits of CBT, the science of genetics, epigenetics and neurotasticity. Today we bring it together and ask the harder question whether our therapeutic models as they currently stand are adequate for the people who need them most. I want to say clearly this is not a polemic, this is not an attack on therapists, on the NHS or on anyone working inside these systems. Many of them are doing extraordinary work inside structures that limit what they can offer. This is a question about the structures themselves. If you have ever been handed a diagnosis that didn't quite fit what you were experiencing, or sat through six sessions of a standard programme and been told that's all that's available, or being labelled treatment resistant or difficult or complex, as though those words described something wrong with you rather than something insufficient about the help on offer. You already know in your body what this episode is about. There is a particular kind of exhaustion that comes from trying to fit yourself into a framework that wasn't built for what you're carrying. It's not the exhaustion of the original plan, it's a second additional exhaustion, the work of translating your experience into a shape the system can process. That is not a personal failing, and increasingly the research agrees. The usual thream before we go in. What I am presenting today is a synthesis of published peer-reviewed research and clinical commentary from people who are. Second, the structural and access problems in how mental health care is currently delivered. Third, where the field itself is heading and what a better fitted system might look like. Let's start with the scale of the problem. Depressive disorders have a lifetime prevalence of approximately sixteen percent in the general population. Of the people who seek treatment for depression, a significant proportion do not respond to the first, second or even third treatment attempt. Treatment resistant depression the scale of the problem Lifetime prevalence of depressive disorders 16% of the general population. Standard clinical definition of treatment resistant depression lack of meaningful improvements after two antidepressant trials from different drug classes at adequate dose and duration with documented adherence. Pilot data Turkey 2024-25 after the first treatment trial only 21.1% of patients showed treatment response. Only 30.7% achieved full remission. That means roughly 7 in 10 patients did not achieve full remission after their first treatment attempt. 7 in 10 after the first attempt. Now here is the question worth sitting with. Key finding current diagnostic taxonomy DSM5 ICD ten fails to adequately capture clinically important subtypes. For example, mixed states are often missed by current criteria leading to patients being treated incorrectly. In some cases the wrong treatments can actively worsen symptoms producing what looks like treatment resistance, but is actually a treatment induced complication. 2026 Frontiers in Psychiatry Paper It is time to rethink current definitions and clinical practice around treatment resistance, calling for personalized medicine and a biofisocial approach rather than a fixed staging model. I want to repeat that middle point because it matters enormously. Some treatment resistance is not resistance at all, it is misdiagnosis. A presentation that doesn't fit neatly into the available categories. Treated with an approach designed for a different presentation, sometimes making things worse and then labelled as resistance when the resistance was never really there. This is not a fringe academic argument. This is published in mainstream psychiatric journals by researchers working alongside inside the field asking their own profession to look more carefully at its own assumptions. Beyond the question of whether the right treatment is offered is a more basic question whether any treatment is offered in time or at all. Access to care the European and global picture. European Psychiatric Association 2025 One in four European citizens report that they or their family members have faced barriers to accessing mental health care, including long waiting lists and high treatment costs. World Health Organization Roadmap for Mental Health Policy Reform October 2025. Mental health systems across the world remain in urgent need of reform. High quality community-based services are scarce, waiting lists are unacceptably long, and rights-based person-centered recovery oriented interventions, though evidence-based, have yet to be meaningfully integrated into policy or practice. Mental health services too often remains focused on diagnosis and medication rather than the full picture of a person's life and context. Mental Health Services 2 often remains focused on diagnosis and medication. That sentence from a World Health Organization policy paper published in 2025 is about as direct a critique of the current model as you will find from an institutional source. And it matches something many of us already know from lived experience. That being handed a diagnosis and a prescription is not the same thing as being understood. There is also a structural issue in how care is currently allocated. Stepped care the most the model most people encounter. Most public mental health systems, including NHS talking therapies, use a stepped care model. Everyone starts at the lowest intensity intervention and only moves to more intensive supports if the first level fails. Research Critique Marburg Declaration 2025 4. While stepped care approaches lead to an efficient allocation of sparsely available conditions, they can delay access to higher levels of care for those patients who need them from the beginning. The alternative stratified care assesses a person upfront and matches them to the right level of intervention immediately, rather than making them fail at a lower level first. A 2022 JAMA psychiatry trial found stratified care produced better outcomes than step care for depression. In plain terms, the system that most people encounter is designed to start everyone at the cheapest, lowest intensity option and only escalate them once that has been tried and has failed. For someone with a straightforward single episode difficulty that might be appropriate. For someone carrying complex trauma, 20 years of accumulative difficulty, or a presentation that doesn't fit the standard categories, that means being made to fail at an intervention that was never going to be sufficient before being allowed access to something that might actually fit. And the evidence, the 2022 Jama Psychiatry Trial I just mentioned, suggests that matching people to the right level of care from the start produces better outcomes than making everyone start at the bottom. I don't want this episode to end in critique alone because the honest picture includes something else. A genuine growing movement within psychiatry itself to change how care is delivered. It's called precision psychiatry or personalized psychiatry and the language researchers are using to describe rights needed echoes exactly what we've been discussing. Precision psychiatry the emerging model called promise core premise a one-size-fits-all approach is inadequate to guide clinical care because people differ in ways that are not captured by broad diagnostic categories. Precision psychiatry incorporates genetic markers, brain imaging data, environmental history and personal context to match individuals to the treatment most likely to work for them. Specifically, rather than a population average, 2025 was described by researchers as a true tipping point for functional and precision psychiatry, with a wave of high-quality research moving biological, nutritional and metabolic drivers of mental health from margins to the center of clinical conversation. APA 2025 FMRI guided therapy trials are already showing measurable brain changes providing with improved outcomes. This matters because it confirms something this entire episode has been building toward. The field is not static. Researchers inside psychiatry are actively building the case for exactly the kind of individualized context-over care that complex presentations actually need. In an overstretched public system, that gap between what the research increasingly supports and what is actually delivered on ground is revealed and significant and largely a matter of funding and capacity. But the direction of travel is honest and important to name. The argument that the model needs to fit the person, not the person to fit the model, is no longer a film's position. It is increasingly the mainstream scientific consensus. I want to draw together everything we've covered across these first five episodes because I think it adds up to something. We started with the statistics of abuse, 13.6 million people, a number that counts but cannot hold. We looked at the origins of CBT, a genuinely valuable model built for specific conditions, expanded to become a default for far beyond what the original evidence base supports. We looked at genetics, epigenetics and neuroplasticity and found that biology is not destiny. It is a conversation between inheritance, experience, and ongoing capacity for change. And today we looked at the systems that are supposed to bring all of that understanding into actual care and found that those systems as currently built and currently funded often default to the broadest, cheapest, most standardized option, and only escalate once that option has been tried and has failed. Put all of that together and a pattern emerges. The science of mental health has become significantly more nuanced, more individualized and more honest about complexity, faster than the systems delivering care have been able to adapt. That gap is not your fault, it was never your fault. If a model didn't fit what you are carrying, that is information about the model, not a verdict on you. What I would like what I would ask you to take from this whole series is not despair about the gap, it is a different kind of permission. Permission to keep looking for the approach that actually fits, rather than assuming that one failed attempt means nothing will work. The research increasingly agrees with you, the field is moving, even if slowly, and you are allowed to keep asking for something that fits rather than settling for something that doesn't. Five episodes ago I asked whether a person who has been through what I've been through can actually be understood by the systems that are supposed to help them. I don't have a clean answer to that question. I told you at the start of this series that I wouldn't, that was never going to be this show. But here's what I can say honestly. After five episodes looking at the evidence as carefully as I can, the systems are imperfect, sometimes significantly so. The gap between what the research supports and what gets delivered is real and it costs people time and trust and hope. But the field is not standing still, and the people doing the research are increasingly asking the same questions you have probably asked in the dark. Whether the model fits, whether the resistance is really yours, whether something better is possible. You are not broken, you are not failing. You may simply not yet have found the approach that was built for what you're actually carrying. That search is allowed to continue. Not fixed, still here, still looking. That brings us to the end of our first five episodes together. Thank you for being here for them. There is more to come, more questions worth asking, more science worth sitting with, more honesty about what it's actually like to live this. I'll be back with episode 6 soon and I'll let you know what we're getting into. That's not fixed, it's still here. Episode 5. If anything in today's episode or this series brought something up for you, please reach out for support. You can call or text 988 the Suicide and Crisis Liveline, free confidential available 24 hours a day. Or text home to 741-741. The Crisis Textline also free, confidential and available anytime. If you've been with me for all five episodes so far, thank you genuinely. You can find this show wherever you listen to your podcasts. If it meant something to you, please share it with someone who might need it. I'm Toran, I'll be back for episode six. Take care of yourself.