The term was first coined with the development of the first aid for psychiatry clerkship pdf in 1974. Inadequate response has traditionally been defined as no response whatsoever. However, many clinicians consider a response inadequate if the patient does not achieve full remission of symptoms. Cases of treatment-resistant depression in which the course of treatment was not adequate are sometimes referred to as pseudoresistant.
Some factors that contribute to inadequate treatment are: early discontinuation of treatment, insufficient dosage of medication, patient noncompliance, misdiagnosis, and concurrent psychiatric disorders. Treatment-resistance is relatively common in cases of MDD. Rates of total remission following antidepressant treatment are only 50. Comorbid psychiatric disorders commonly go undetected in the treatment of depression. If left untreated, the symptoms of these disorders can interfere with both evaluation and treatment. Anxiety disorders are one of the most common disorder types associated with treatment-resistant depression.
The two disorders commonly co-exist, and have some similar symptoms. Some studies have shown that patients with both MDD and panic disorder are the most likely to be nonresponsive to treatment. Substance abuse may also be a predictor of treatment-resistant depression. It may cause depressed patients to be noncompliant in their treatment, and the effects of certain substances can worsen the effects of depression. Other psychiatric disorders that may predict treatment-resistant depression include personality disorders, obsessive compulsive disorder, and eating disorders. Some patients who are diagnosed with treatment-resistant depression may have an underlying undiagnosed health condition that is causing or contributing to their depression. Another factor is that medications used to treat comorbid medical disorders may lessen the effectiveness of antidepressants or cause depression symptoms.
Cases of depression in which the patient also displays psychotic symptoms such as delusions or hallucinations are more likely to be treatment resistant. Another depressive feature that has been associated with poor response to treatment is longer duration of depressive episodes. Finally, patients with more severe depression and those who are suicidal are more likely to be nonresponsive to antidepressant treatment. There are three basic categories of drug treatment that can be used when a medication course is found to be ineffective. One option is to switch the patient to a different medication. Another option is to add a medication to the patient’s current treatment.
This can include combination therapy: the combination of two different types of antidepressants, or augmentation therapy: the addition of a non-antidepressant medication that may increase the effectiveness of the antidepressant. Increasing the dosage of an antidepressant is a common strategy to treat depression that does not respond after adequate treatment duration. Practitioners who use this strategy will usually increase the dose until the patient reports intolerable side effects, symptoms are eliminated, or the dose is increased to the limit of what is considered safe. SSRI were responsive after taking a second type.
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Switching patients to a different class of antidepressants may also be effective. Adding lithium may be effective for patients taking some types of antidepressants, I it does not appear to be effective in patients taking SSRI’s. Benzodiazepines may improve treatment-resistant depression by decreasing the adverse side effects caused by some antidepressants and therefore increasing patient compliance. Particularly, the combination of olanzapine and fluoxetine seems to be effective.
These have shown promise in treating refractory depression but come with serious side effects. It is used when medication has repeatedly failed to improve symptoms, and usually when the patient’s symptoms are so severe that they have been hospitalized. Electroconvulsive therapy has been found to reduce thoughts of suicide and relieve depressive symptoms. It is associated with an increase in glial cell line derived neurotrophic factor. Like electroconvulsive therapy, it is usually only used in severe cases of treatment-resistant depression that have been non-responsive to medication. However, a review of the literature suggests that it may be an effective treatment option. Psychotherapy may be effective in these cases because it can help relieve stress that may contribute to depressive symptoms.