"What else can we do?"-Provider perspectives on treatment-resistant depression in late life.

BACKGROUND: Treatment-resistant depression in late-life (TRLLD) is common. Perspectives of primary care providers (PCPs) and psychiatrists treating TRLLD could give insights into the challenges and potential solutions for managing this condition. METHODS: To identify perspectives of providers who treat TRLLD, we conducted a qualitative descriptive study using semi-structured interviews with providers treating older adults with TRLLD in five locations across North America (i.e., Los Angeles, New York City, Pittsburgh, St. Louis, and Toronto). We conducted semi-structured interviews with 50 care providers (24 primary care providers [PCPs], 22 psychiatrists, and 4 depression care managers). Interviews elicited providers' perspectives on treatment options for TRLLD, including treatment within the primary care setting and referral to psychiatry, and sought suggestions for improvement. RESULTS: We identified four themes. (1) Treating TRLLD takes an emotional toll on providers; (2) existing psychiatric services are inadequate to meet the needs of patients with TRLLD, mainly because of lack of access; (3) PCPs often attempt to treat TRLLD, even when they are not comfortable doing so; and (4) to better meet the needs of patients with TRLLD, providers recommend integrated care models involving PCPs, psychiatrists, and psychotherapists, potentially made more feasible by the growth of telehealth. CONCLUSIONS: Findings from these qualitative interviews show the challenges in providing care for TRLLD. These findings can guide knowledge dissemination to psychiatrists, PCPs, policy-makers, and other stakeholders involved in the mental health system. They can also inform structural changes to clinical practice that may increase the implementation of the best treatment strategies across settings to improve long-term outcomes for TRLLD.