Managing patients with “treatment resistant depression” offers a major challenge to clinical psychiatrists, psychopharmacologists, and others. Firstly, patient heterogeneity must be recognized in terms of symptom presentation, biological variables, co-morbidity with other psychiatric and medical disorders and associated personality disorder. Secondly, a rigorous approach to the treatment resistant patient must allow for adequate individual and combination therapies including heterocyclic agents, monoamine oxidase inhibitors, electroconvulsive therapy, and augmentation with lithium carbonate or thyroid hormone. The novel antidepressant therapies have not so far altered the relapsing course of depressive illness for many patients.
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