Treatment Strategies and Tactics for Treatment-resistant Depression

Treatment Strategies and Tactics for Treatment-resistant Depression

Daly Ella J

US Psychiatry 2007;1:17-20

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Treatment-resistant depression (TRD)—depression that does not remit after one or more adequately delivered treatments1,2—is a major and increasing public health burden due to its high prevalence, chronic and recurrent course, substantial morbidity, and significant direct and indirect costs.3–5Treatment for this condition needs to be aimed at effecting full remission (e.g. absence of symptoms) rather than response, since anything short of remission is likely to result in relapse, recurrence, and future treatment resistance.6–8

The recent National Institute of Mental Health (NIMH)-funded Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study showed that remission rates are modest even after two state-of-the-art, diligently delivered treatment steps with the support of depression-care specialists.9–11 Even following four steps, a large percentage of patients who do not benefit remains.8

Available treatment strategies, as currently implemented, are relatively ineffective for patients in later stages of TRD, for example those who have ot achieved remission despite several adequately delivered treatments.8,12–14 Specifically, current research on TRD fails to guide practicing physicians about which treatment sequences are the most effective, with even greater uncertainty about which specific treatment sequence is most effective for individual patients. Given that there is considerable response heterogeneity among individuals, and insufficient understanding of who responds to what treatment, the treatment process is often little more than trial and error until an appropriate treatment is found. There is a clear need for empirically based information to identify effective treatments and use them earlier— thereby reducing the steps needed to achieve remission—and to determine how to individualize and tailor treatment for a particular patient. The fact that 60–70% of all patients with major depressive disorder (MDD) meet criteria for TRD underscores the need for systematic development of innovative treatments for TRD.15–17

strong>Treatment-resistant Depression
Treatment-resistant depression is a common problem in the treatment of MDD, yet little agreement exists about either the definition of TRD or evidence-based options for treatment. There is likely a continuum of treatment resistance, with modest resistance referring to failure to fully respond to one adequate treatment trial, and greater resistance referring to failure to respond to two or more adequate treatment trials or one trial of augmentation.11,18

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