Definition, Assessment, and Staging of Treatment—Resistant Refractory Major Depression: A Review of Current Concepts and Methods

Abstract

Up to 15% of depression patients eventually present with treatment-resistant or refractory depression (TRD), a condition that causes significant social and economic burdens. Our paper aims to summarize the current medical literature on the conceptual and methodologic issues involved in the definition, assessment, and staging of TRD. Method: We reviewed the recently published medical literature to identify papers that specifically discuss TRD. For this, we searched MEDLINE, EMBASE, and PsycINFO for potentially relevant English-language articles published between January 1996 and June 2006. Results: Recent methodologic and conceptual advances have contributed to the achievement of an acceptable level of theoretical consensus on the general meaning of TRD. Accordingly, depression is usually considered resistant or refractory when at least 2 trials with antidepressants from different pharmacologic classes (adequate in terms of dosage, duration, and compliance) fail to produce a significant clinical improvement. Regarding diagnostic assessments, an accurate and systematic evaluation should be made to elicit the potential role of several contributing factors, such as medical and psychiatric comorbidity. Conclusion: Recently, 3 staging methods for TRD have been described, but they currently require extensive empirical support. Future research on TRD should include prospective studies addressing the validity of the proposed criteria, the impact of depression comorbid with other psychiatric disorders and (or) physical conditions, and the possible predictors of treatment outcome. There is an important and clear need for studies that empirically test current definitions, assessment strategies, and staging methods of TRD.

Neuromodulation approaches for the treatment of major depression: challenges and recommendations from a working group meeting

“…In addition, depression is a chronic, recurrent disorder, as nearly 80% of patients relapse after the treatment of an episode 4 . Finally, about one third of patients have treatment-resistant depression (TRD), which is defined as the failure to achieve adequate response of symptoms after two or more antidepressant treatment trials 9,10 . In fact, the high prevalence of TRD, associated with failure to antidepressant response, is an important concern when managing major depression.…”

Current Nosology of Treatment Resistant Depression: A Controversy Resistant to Revision

“…It is important to evaluate patients with TRD specifically for a history of manic or hypomanic episodes to rule out bipolar spectrum disorders since depressive episodes may be the (only) clinical presentation of Bipolar Disorders (BDs) for many years [28].…”

“…The implication for treatment is to address these conditions simultaneously, if possible, to avoid consolidating treatment resistance [28].…”

Antipsicóticos atípicos na depressão refratária

“…A ausência de um modelo de estadiamento universalmente aceito que descreva adequadamente a falha ao tratamento e grau de resistência leva a inúmeras variações nas definições de depressão refratária, com consequente dificuldade no estabelecimento de uma proposta de algoritmo para essa condição. Berlim e Turecki 8 , em revisão recente sobre definições e critérios de depressão refratária, demonstraram a falta de consenso na literatura no que diz respeito à definição da síndrome depressiva e à responsividade ao tratamento.…”