Depression in certain types of individuals carry an increased risk of suicide. In the context of untreated high risk factors and increasing despair, it is no mystery that treatment-resistant depression (trd)/treatment-refractory depression (TRD) accentuates the risk of suicide inherent in a high risk individual. It seems important to consider both chronic and acute risk factors in the assessment of suicide risk, especially when deciding on intervention strategies and tactics. Studies of nearly 100 inpatient suicide records and approximately 30 outpatient suicide cases suggest four typical clinical patterns. Illustrative case vignettes are presented to emphasize these observed patterns. These patterns are not by any means exhaustive, but may be a useful beginning for the clinician treating various forms of treatment-resistant or refractory depression to be able to recognize. Expertise in the treatment of resistant depression is a skill that every practicing clinician should develop.