A clinical approach to treatment resistance in depressed patients: What to do when the usual treatments don’t work well enough? (original) (raw)
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Prevalence and management of treatment-resistant depression
The Journal of clinical psychiatry, 2007
Treatment-resistant depression (TRD) is a major public health problem in terms of its prevalence and in terms of individual suffering and cost to society. Best estimates indicate 12-month prevalence rates of approximately 3% for Stage 1 TRD (failure to respond to 1 adequate trial of an antidepressant) and approximately 2% for Stage 2 TRD (failure to respond to 2 adequate trials). The current article provides a brief review of the definitions, prevalence, and various treatment options for TRD, including switching, augmentation, and combination therapies and use of nonpharmacologic treatments. Given the public health importance of TRD, the relative absence of adequately powered, double-blind trials is striking.
CNS spectrums, 2004
Treatment-resistant depression (TRD) represents a significant challenge for physicians. About one third of patients with major depressive disorder fail to experience sufficient symptom improvement despite adequate treatment. Despite this high occurrence of TRD there was no general consensus on diagnosis criteria for TRD until 1997 when researchers proposed a model of defining and staging TRD. In 1999, others defined operational criteria for the definition of TRD. Treatment of TRD is commonly separated into pharmacologic and nonpharmacologic methods. This review gives a short overview of these two methods. The nonpharmacologic methods include psychotherapy, electroconvulsive therapy, and vagus nerve stimulation. Pharmacologic methods include switching to another antidepressant monotherapy, and augmentation or combination with two or more antidepressants or other agents. This review especially focuses on the augmentation of the antidepressant therapy with atypical antipsychotics.
Treatment resistant depression: methodological overview and operational criteria
European Neuropsychopharmacology, 1999
A wide variety of definitions are used for Treatment Resistant Depression (TRD), considering various criteria and different concepts. Some of the key issues are: the diagnosis, the treatment adequacy in terms of dose and duration, the treatment response assessment and the number of failed therapeutic trials required. Systematic research has been characterizing the concept and criteria to define the different variables involved. Lack of consensus on these issues limits comparison across clinical trials and interpretation of treatment efficacy in the management of treatment resistant patients. Through reanalyzes of available data, we point out the limits of TRD definitions and propose conceptual and operational criteria for a collaborative research project on TRD. It appears that a number of variables commonly associated to treatment resistance are independent of patients characteristics and mainly refer to misdiagnosis and inadequate treatment. The proposed criteria are intended for therapeutic trials in TRD, combining the evaluation of treatment efficiency and the validation of the concept of TRD itself. Major depression with poor response to two adequate trials of different classes of antidepressants is proposed for an operational definition of TRD. Rationale for this definition is discussed in contrast to alternative definitions.