The concept of “treatment resistant depression” (TRD) has generally been defined in terms of failure to respond to a standard course of somatic therapy with little reference to diagnostic sub-types or relevant psychosocial factors. In this paper we examine problems with the use of the term “treatment resistant depression” and then outline an approach to TRD employed in an Australian mood disorders unit. After discussing the need for a biopsychosocial assessment, multimodal management strategies for melancholic and non-melancholic TRD patients are described.
References
1.
HeimannH.Therapy-resistant depressions: symptoms and syndromes: contributions to symptomatology and syndromes. Pharmakopsychiatry Neuropsychopharmacology1974; 7:139–144.
2.
LehmannHE.Therapy-resistant depressions — a clinical classification. Pharmakopsychiatry Neuropsychopharmacology1974; 7:156–163.
3.
FawcettJKravitzHM.Treatment refractory depression. In: SchatzbergAJ, ed. Common treatment problems — depression. American Psychiatric Press: Washington DC, 1985.
4.
NierenbergAAKeckPEJrSamsonJRothschildAJSchatzbergAFMethodological considerations for the study of treatment-resistant depression. In: AmsterdamJD, ed. Advances in neuropsychiatry and pychopharmacology, Volume 2: Refractory depression. Raven Press: New York, 1991.
5.
NierenbergAAAmsterdamJD.Treatment-resistant depression: Definition and treatment approaches. Journal of Clinical Psychiatry1990; 51 [suppl 6]: 39–47.
6.
NierenbergAAWhiteK.What next?: A review of pharmacologic strategies for treatment resistant depression. Psychopharmacology Bulletin1990; 26: 429–460.
7.
GlassmanAHRooseSP.Tricyclic treatment: what is adequate and who is refractory?Review of Psychiatry, Volume 9. American Psychiatric Press: Washington DC, 1990.
8.
GuscottRGrafP.The clinical meaning of refractory depression: A review for the clinician. American Journal of Psychiatry1991; 148:695–704.
9.
American Psychiatric Association.Diagnostic and Statistical Manual for Mental Disorders (3rd edition). APA: Washington DC, 1980.
10.
American Psychiatric Association.Diagnostic and Statistical Manual for Mental Disorders (Revised 3rd edition). APA: Washington DC, 1987.
11.
The Quality Assurance Project.A treatment outline for depressive disorders. Australian and New Zealand Journal of Psychiatry1983; 17: 129–146.
12.
ArmstrongMAndrewsG.A survey of practising psychiatrists' views on treatment of the depressions. British Journal of Psychiatry1986; 149:742–750.
13.
KupferDJ.Long-term treatment of depression. Journal of Clinical Psychiatry1991; [suppl 5]: 28–34.
14.
FrankEPrienRFJarrettRBKellerMBKupferDJLavoriPWRushAJWeissmanMM.Conceptualization and rationale for consensus definitions of terms in Major Depressive Disorder. Archives of General Psychiatry1991; 48:851–855.
15.
ScottJ.Chronic depression. British Journal of Psychiatry1988; 153:287–297.
16.
CassanoGBMagginiCAkiskalHS.Short-term, subchronic, and chronic sequelae of affective disorders. Psychiatric Clinics of North America1983; 6:55–67.
17.
CoyneJC.Toward an interactional description of depression. Psychiatry1976; 39:28–40.
18.
CoyneJCKesslerRCTaiMTurnbullJWortmanCBGredenJF.Living with a depressed person. Journal of Consulting Clinical Psychology1987; 55:347–352.
19.
DugganCFLeeASMurrayRM.Does personality predict long-term outcome in depression?British Journal of Psychiatry1990; 157:19–24.
20.
WeissmanMMPrusoffBAKlermanGL.Personality and the prediction of long-term outcome of depression. American Journal of Psychiatry1978; 135:797–800.
21.
AndrewsGNeilsonMHuntJStewartGKilohLG.Diagnosis, personality and the long-term outcome of depression. British Journal of Psychiatry1990; 157: 13–18.
22.
BoycePParkerGHickieIWilhelmKBrodatyHMitchellP.Personality differences between patients with remitted melancholic and non-melancholic depression. American Journal of Psychiatry1990; 147: 1476–1483.
23.
PilkonisPAFrankE.Personality pathology in recurrent depression: Nature, prevalence, and relationship to treatment response. American Journal of Psychiatry1988; 145:435–441.
24.
RohdePLewinsohnPMSeeleyJR.Are people changed by the experience of having an episode of depression? A further test of the scar hypothesis. Journal of Abnormal Psychology1990; 99:264–271.
25.
HafnerRJ.Marriage and mental illness. Guilford Press: New York, 1986.
26.
HickieIWilhelmKParkerGBoycePHadzi-PavlovicDBrodatyHMitchellP.Perceived dysfunctional intimate relationships: a specific association with the non-melancholic depressive subtype. Journal of Affective Disorders1990; 19:99–107.
27.
HickieIParkerG.The impact of an uncaring partner on improvement in non-melancholic depression. Journal of Affective Disorders1992; 147–160.
28.
WilhelmKMitchellPSengozAHickieIBrodatyHBoyceP.Treatment resistant depression in an Australian context II. Outcome of a series of patients. Australian and New Zealand Journal of Psychiatry1994; 28: 23–33.
29.
BrodatyHBoycePWilhelmKMitchellPParkerG.The establishment of a mood disorders unit. Australian and New Zealand Journal of Psychiatry1987; 21:375–381.
30.
ParkerGHadzi-PavlovicHBoycePWilhelmKBrodatyHMitchellPHickieIEyersK.Classifying depression by mental state signs. British Journal of Psychiatry1990; 157: 55–65.
31.
ParkerGHallWBoycePHadzi-PavlovicHMitchellPBrodatyHWilhelmKHickieIEyersK.Depression sub-typing: Unitary, binary or arbitrary?Australian and New Zealand Journal of Psychiatry1991; 25:63–76.
32.
RobinsCJBlockPPeselowED.Specificity of symptoms in RDC endogenous depression. Journal of Affective Disorders1989; 16:243–243.
33.
NelsonJCMazureCMJatlowPI.Does melancholia predict response in major depression?Journal of Affective Disorders1990; 18:157–165.
34.
WolpeJ.The renascence of neurotic depression: its varied dynamics and implications for outcome research. Journal of Nervous and Mental Disease1988; 176: 607–613.
35.
WinokurG.The validity of neurotic-reactive depression: new data and reappraisal. Archives of General Psychiatry1985; 1116–1122.
36.
PeselowEDSanfilipoMSDifigliaCFieveRR.Melancholic/endogenous depression and response to somatic treatment and placebo. American Journal of Psychiatry1992; 149:1324–1334.
37.
HickieIParsonageBParkerG.Prediction of response to electroconvulsive therapy. Preliminary validation of a sign-based typology of depression. British Journal of Psychiatry1990; 157: 65–71.
38.
LeeASMurrayRM.The long-term outcome of Maudsley depressives. British Journal of Psychiatry1988; 153:741–751.
39.
LishmanWA.The psychological consequences of cerebral disorder. Blackwell Scientific: London, 1987.
CoffeyCEFigielGSDjangWTWeinerRD.Subcortical hyperintensity on magnetic resonance imaging: a comparison of normal and depressed elderly subjects. American Journal of Psychiatry1990; 147:187–189.
42.
HickieIScottEMitchellPWilhelmKAustinMPBennettB.Subcortical hyperintensities on magnetic resonance imaging: Clinical correlates and prognostic significance in patients with severe depression. Submitted for publication.
43.
MitchellP.The pharmacological treatment of tricyclic-resistant depression: Review and management guidelines. Australian and New Zealand Journal of Psychiatry1987; 21:442–451.
44.
PotterWZRudorferMVManjiH.The pharmacologic treatment of depression. New England Journal of Medicine1991; 325:633–642.
45.
PreskornSHFastGA.Therapeutic drug monitoring for antidepressants: Efficacy, safety, and cost effectiveness. Journal of Clinical Psychiatry1991; 52 [suppl 6]:23–33.
46.
SchatzbergA.Dosing strategies for antidepressant agents. Journal of Clinical Psychiatry1991; 52 [suppl 5]: 14–20.
47.
TollefsonGD.Antidepressant treatment and side effect considerations. Journal of Clinical Psychiatry1991; [suppl 5]: 4–13.
48.
SackeimHAPrudicJDevanandDP.Treatment of medication-resistant depression with electroconvulsive therapy. In: Review of Psychiatry, Volume 9. American Psychiatric Press: Washington DC, 1990.
49.
SackeimHAPrudicJDevanandDPKierskyJEFitzsimonsLMoodyBJMcElhineyMCColemanEASettembrinoJM.Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electro convulsive therapy. New England Journal of Medicine1993; 328:839–846.
50.
AustinM-PVSouzaFGMGoodwinGM.Lithium augmentation in antidepressant-resistant patients: A quantitative analysis. British Journal of Psychiatry1991; 159:510–514.
51.
CullenMMitchellPBrodatyHBoycePParkerGHickieIWilhelmK.Carbamazepine for treatment-resistant melancholia. Journal of Clinical Psychiatry1991; 52:472–476.
52.
WeilburgJBRosenbaumJFBiedermanJSachsGSPollackMHKellyK.Fluoxetine added to non-MAOI antidepressants converts nonresponders to responders: A preliminary report. Journal of Clinical Psychiatry1989; 50:447–449.
53.
BouckomsA.The role of stereotactic cingulotomy in the treatment of intractable depression. In: AmsterdamJD, ed. Advances in neuropsychiatry and psychopharmacology, Volume 2: Refractory depression. Raven Press: New York, 1991.
54.
QuitkinFMStewartJWMcGrathPJLiebowitzMRHarrisonWMTricamoEKleinDFRabkinJGMarkowitzJSWagerSG.Phenelzine versus imipramine in the treatment of probable atypical depression: defining syndrome boundaries of selective MAOI responders. American Journal of Psychiatry1988; 145:306–311.
55.
BrodatyHHarrisLHickieIWilhelmKBoycePMitchellPParkerGEyersK.Lessons from a mood disorders unit. Australian and New Zealand Journal of Psychiatry1993; 27:254–263.
