Management of Treatment Resistant Depression

This presentation focuses on the factors associated with treatment-resistance including a history of child abuse and neglect, prominent anxiety and certain comorbid medical and psychiatric conditions.

It is now well-established that a minority of patients with major depression attain remission after treatment with antidepressant mono-therapy.

The importance of accurate diagnosis is highlighted including family history and evaluation for medical disorders associated with poor treatment response such as hypothyroidism and hypogonadism. Once a patient has failed an adequate trial of an antidepressant, a decision to either:                                             

1) increase the dose of the current antidepressant,
2) engage in combination therapy of the current agent and another antidepressant or evidence-based psychotherapy (e.g. CBT),
3) utilize an augmentation strategy by adding an agent (e.g. lithium or T3) that is not an effective antidepressant, but when added to an antidepressant converts non-remitters to remitters
4) switch to an entirely different antidepressant class, e.g. SSRI→SNRI or SSRI→MAOI 5) use a somatic non-pharmacological approach such as rTMS, VNS, or ECT.

The evidence for these approaches will be summarized.
Finally, the status of experimental treatments including ketamine and DBS is discussed.

At the end of this session, participants will be able to:

1. Understand factors associated with treatment resistant depression and the importance of accurate diagnosis for medical disorders associated with poor treatment response
2. Consider and weigh different options for deciding on how to address depression after the patient’s failure of an adequate trial of an antidepressant
3. Touch upon the status of experimental treatments such as ketamine and DBS

Presentation Level: Intermediate to Advanced: Assumes knowledge of basic treatment of depression with antidepressants and psychotherapy.

This webinar is not eligible for CE credit.