There is a specific moment inside these appointments, and it usually happens near the end.
The patient has already described the last two months. There was no dramatic worsening, nothing new — it was all more or less the same, which is what he has been saying for quite a while now. The doctor listens, looks at the screen, scrolls through the list of what has already been used. There are a few seconds of silence that nobody comments on.
And then someone asks the question. Sometimes it is the patient, sometimes the daughter who came along, sometimes the doctor thinking out loud: “so what do we try now?”
Outside, in the waiting room, there is a plastic folder full of old prescriptions. Some families keep everything. You could reconstruct six or eight years of treatment from those sheets — names following one another, doses going up, combinations added and then unpicked, each of them prescribed by someone competent, each of them with a good reason for having been tried at that moment.
When that folder gets too thick, something has changed in nature, even if the appointments carry on exactly as before.
Perhaps you recognized that scene because you have sat in the chair. Or perhaps you recognized it because you are the one who has been taking someone to these appointments for years, and you know that plastic folder by heart. If so, either way, it is worth saying: if you have come to think there may be nothing left to do, there would be nothing irrational about that. It would be the predictable conclusion of anyone who has repeated the same sequence many times and got the same result. Except that “the next change probably will not fix this” and “there is nothing to be done” are different sentences, and the distance between them is what this article is about.
When the right question stops being “what’s next”
In the early attempts, the logic of changing makes complete sense. Some people respond to the first choice, others to the second, and adjusting until something works is reasonable medicine, practiced every day, with good results.
What happens is that this logic has a limit, and the limit is not mathematical — there is no magic number of attempts after which everything changes. What there is, is a shift in probability: the more adequate attempts accumulate without a response, the smaller the chance that the next one is simply the right one, and the greater the chance that something else is going on that has not yet been identified.
At that point, carrying on asking “what’s next” is not wrong. It is just not enough. It is like replacing the part without having reopened the diagnosis of the machine.
And here a note that tends to clarify things: counting how many treatments someone has taken tells you less than it seems. Plenty of people arrive saying “I’ve already tried ten”. When the history is put back together slowly, it sometimes turns out that several of those attempts were interrupted before they had any chance to show anything — because of an unwanted effect, because of cost, because of a trip abroad, because of a stretch when the person stopped without telling anyone. Those were attempts started, not attempts completed. That is nobody’s failure; it is what happens when a treatment stretches across years and passes through several doctors.
But the difference between ten attempts and three genuinely completed ones changes the reading of the case entirely. And that distinction does not appear in the plastic folder. It only appears when somebody sits down and goes back over the whole history, year by year.
The first thing to reopen is the diagnosis
This is the part that tends to be uncomfortable, and it is the most important one.
When something does not respond to successive, well-conducted treatments, the hypothesis that needs re-examining before any other is not the one about the medication. It is the one about the diagnosis.
That does not mean the doctors before got it wrong. It means that certain conditions present, at the beginning, with only one face — and that this face can be indistinguishable from an ordinary depression for years. The piece of information that would have made the difference often was not available at the first appointment: either it had not happened yet, or it happened and nobody asked, or it was asked about and the person, in that state, could not tell it properly.
That is why reassessing a resistant case does not start where the last doctor stopped. It starts from scratch. The timeline is rebuilt from adolescence onwards, you look for the shape of episodes across a life, you ask what was happening in the stretches when the person was well — and not only in the ones when they were unwell. Where possible, you listen to the people who live with them, because there are things nobody can see in themselves.
Sometimes that work confirms exactly what was already known. And confirming has value: you go on to treat a resistant condition knowing that is what it is, instead of treating an ordinary depression that inexplicably is not improving. Other times what emerges is a different reading of the whole case — and from there the clinical decisions become different ones. Which ones, specifically, is a matter for the consulting room, not for an article.
What else may be holding the picture up
A depressed state that lasts for years is rarely held up by one thing alone. When the assessment is genuinely redone, it has to look at everything that might be keeping it standing — and a good deal of that is not psychiatric.
There are general medical conditions that produce or perpetuate depressive states and that are easily missed, because the symptoms overlap. There is what happens to sleep across years of illness, which stops being a consequence and becomes a cause. There is chronic pain. There are everyday substances, alcohol included, whose part in it is rarely measured honestly. There are treatments used for other purposes whose effect on mood nobody has added up. And there are the effects the illness itself produced — the job lost, the isolation, the relationship that deteriorated — which at a certain point begin to feed the picture on their own, regardless of what started it.
None of that is resolved by choosing something different, and none of it turns up if nobody goes looking.
Why this takes time in the room
Redoing an assessment of this kind does not fit into fifteen or twenty minutes, and it is honest to say so rather than pretend otherwise.
Rebuilding three decades of history, going through old records, understanding what actually happened in each previous attempt, listening to the family, reviewing what else is at stake clinically — that is hours of work, not a follow-up appointment. It is the most concrete difference between a reassessment and a hurried second opinion, which tends to reach the same conclusions because it started from the same summary.
If you have been to several doctors and had the feeling that they all heard the short version of your story, they probably did. Not out of carelessness: because the long version did not fit the time available.
What this article is not saying
Three things, and I would rather leave them in writing.
I am not saying that the treatment so far was wrong, or that the previous doctors failed. In most of the cases I see, the decisions were defensible given the information that existed.
I am not saying there is a right treatment out there waiting to be discovered. That promise is made often and it does not hold up.
And I am not saying what should be done in your case, or in your mother’s case. That cannot be said without examining the person, and any text that says it is deceiving you.
What I am saying is only that there comes a point where the question changes. It stops being “what do we try now” and becomes “what exactly are we treating, and what else is holding this up”. Those are different questions, and they lead to different appointments.
If you are at that point
You do not have to conclude anything today. You do not have to change doctors, you do not have to challenge the person treating you, you do not have to make any decision this week.
Perhaps it is enough to hold on to the distinction: years without a response indicate that the assessment needs redoing, not necessarily that the case has no way out. When it makes sense to you to look at this again, with the time the subject asks for, there is somewhere for that.
Does changing medication no longer seem to be the answer?
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Dr. Leonardo Sodré is a psychiatrist and psychotherapist in Brasília, Brazil (CRM-DF 14.206 · RQE 14.761). He holds a PhD in Psychiatry from UFRGS and teaches at the University of Brasília School of Medicine. This content is informational and educational, and does not replace individual clinical evaluation, diagnosis, or treatment.