1. DRUG TREATMENT OF
RESISTANT DEPRESSION
DR SUSHIL KUMAR S V,
MB BS, MD (PSYCHIATRY), MHA, FIPS,
ASSISTANT PROFESSOR, DEPT. OF
PSYCHIATRY
SS INSTITUTE OF MEDICAL SCIENCES,
DAVANGERE, INDIA
2. INTRODUCTION
• Degree of symptom reduction is related to functioning
• Partial responders with residual symptoms have a poorer
prognosis compared to complete remitters
3. CATEGORIES OF RESPONSE
• Response without remission (< 50% but > 25% from baseline
scores)
• Non-response
• Relapse (< 6 months of acute response)
• Recurrences ( > 6 months)
• Recovery (8 week period)
• Breakthrough (Poop out)
4. CATEGORIES OF RESPONSE
• Residual symptoms: irritability, social functioning, dysfunctional
attitudes, depressive cognitions
• Complete remission is the optimal goal (Trivedi &Kleiber, 2001)
• HAMD Score of < 7
5. DEFINITION OF TRD
• Failure to respond to 2 adequate trials of different chemical
classes (Sourey et al, 1999)
• Several Staging Methods
-- CPMP Guidelines
-- Thase & Rush (1997)
-- Massachusetts General Hospital
6. DEFINITION OF TRD
• Adequate dose & adequate duration
• Treatment intolerance (Schatzberg et al, 1983)
• 20% are treatment intolerant
7. FACTORS RELATED TO TRD
• Patient and Treatment related factors
• Diagnosis
-- Bipolarity
-- Psychotic depression
-- Atypical depression
-- Co-morbid conditions
8. STRATEGIES FOR TRD
• Optimizing the dose
• Augmentation
• Combination
• Switching
• No conclusive data identifies the optimal strategy (Nelson,
2003)
9. OPTIMIZING DOSE
• Most do not receive adequate trial (Keller et al, 1986; Dawson et
al, 1999)
• Pseudo Resistant (Sackeim, 2001)
• Failure to use adequate dose for adequate duration have an
iatrogenic effect in increasing resistance
11. OPTIMIZING DOSE
• Structured Antidepressant Treatment History Form (Sackeim,
2001)
• Initial Choice of medication may depend on depressive
symptoms
• Mirtazapine for insomnia; Venlafaxine for anxious depression
(Meoni et al, 2004)
• Venlafaxine > SSRI
12. AUGMENTATION
• Adding an agent that is not a standard antidepressant
• Lithium (Joffe et al, 1993; Nierenberg et al, 2003)
• Triiodothyronine (T3 > T4) (Joffe et al, 1993)
