Inadequate response to antidepressants or psychological interventions is not uncommon among patients seen in clinical practice. This article reviews possible biological and psychosocial causes of poor response in people with depression and discusses options for management.
- Initially ensure that patients with depression have received an adequate dose and duration of appropriate treatment, be that antidepressants and/or psychological treatment.
- Review ‘treatment-resistant’ patients for possible causes of a poor response to treatment.
- There are a number of well-studied treatment options for patients who do not respond to initial simple antidepressant treatments.
- As some of the options recommended in this article are not widely used in primary care, GPs should have a low threshold for referring such patients to a psychiatrist experienced in difficult-to-treat depression.
The impact of depression is vastly underestimated. It silently robs individuals not only of their ability to enjoy the simple daily pleasures of life, but moreover affects their capacity to engage with family and friends, and to contribute to their workplace and broader community.
At a national level, the Australian National Survey of Mental Health and Wellbeing reported that major depressive disorder (MDD; unipolar depression) affected at least 4% of Australians over a year and led to these people being unable, or less able, to carry out their usual activities for six days per month.1 Internationally, the Global Burden of Disease Study reported major depression to be the fifth leading cause of disability.2 Furthermore, depression is associated with a significantly increased mortality rate (at about 70% above usual rates) due to physical conditions such as cardio and cerebrovascular disease, as well as high rates of suicide.3
Many depressed patients do not respond well to treatment
A guide to the treatment of depression has been recently published in Medicine Today and will not be replicated here.4 Rather, this article will focus on an approach to the assessment and treatment of depressed patients who do not respond well to standard treatments; that is, those with treatment-resistant depression (TRD).
The benefit of treatments for depression is measured either in terms of rates of response (i.e. those whose symptoms improve by at least 50%) or rates of remission (i.e. those with no or minimal remaining depressive symptoms). As those who respond may still have significant persisting levels of depression, there is an increasing focus on remission rates, as this is what matters to patients and their families.