Difficult-to-Treat Depression: integrated clinical approaches with Multifamily Therapy and SADAR-guided reflective practice

Abstract

Background. Difficult-to-Treat Depression (DTD) is increasingly recognised as distinct from Treatment-Resistant Depression (TRD). Whereas TRD is defined primarily by non-response to adequately dosed and timed treatments (EMA Guideline Rev.3. 2025), DTD denotes depression that continues to impose substantial burden on patients and families and to engage healthcare services despite usual therapeutic efforts. It highlights the disorder’s multidimensional complexity, clinical, functional, relational, and organizational in a less stigmatising and more clinically relevant frame ((McAllister-Williams et al., 2020); (Rush et al., 2022); (Paganin, 2023) (Demyttenaere et al., 2024). Early recognition enables more personalised and effective care and may reduce stigma. Within this framework we propose the SADAR 3–2–1 method as an innovative post-group reflective tool embedded in Multifamily Therapy (MFT), complementing individual treatments and family support.

Summary
• DTD vs TRD: shift from a pharmacological-resistance focus to a comprehensive management paradigm (Parker, 2024) . • Multifamily Therapy (MFT): promotes shared reflection between patients and families, reduces isolation, discrimination and stereotypes, and strengthens the therapeutic alliance (Badaracco, 2025); (Sempere & Fuenzalida, 2024); (Paganin, 2024). • SADAR method: post-group reflective device structured as 3 resonances (clinical, familial, social), 2 risks of single-perspective readings (e.g., blame, over-medicalisation), and 1 observable next step. SADAR connects clinical practice, ethics, and research by transforming reflective material into observable longitudinal data.

Positioning of SADAR. SADAR is not a patient or family-facing intervention; it is a clinician reflective device used after MFT sessions to discipline metacognitive analysis, reduce confirmation bias, and orient the subsequent clinical step, remaining outside the patient–therapist dyad and preserving the ethical frame.

Research implications. The 3–2–1 formalisation can generate longitudinal narrative archives (resonances, risks, actions) indexed by session/group, amenable to qualitative and quantitative analysis. This enables process-oriented anti-stigma research (language trajectories, shared mentalisation, markers of stigma reduction and alliance improvement) and supports auditability and supervision (Earnshaw et al., 2022); (Lalk et al., 2024).

Conclusion. DTD requires a paradigm shift from resistance to complexity. MFT offers a socio-clinical intervention against stigma, while SADAR strengthens reflective practice and bridges clinical work, ethics, and research. Integrating DTD, MFT, and SADAR underscores the need for multidimensional strategies in managing difficult depression, enhancing mentalisation, fostering resilience, reducing stigma, and opening new avenues for process research.