The identification, assessment and management of difficult-to-treat depression: An international consensus statement

McAllister-Williams, R. Hamish; Arango, Celso; Blier, Pierre; Demyttenaere, Koen; Falkai, Peter; Gorwood, Philip; Hopwood, Malcolm; Javed, Afzal; Kasper, Siegfried; Malhi, Gin S; Soares, Jair C.; Vieta, Eduard; Young, Allan H.; Papadopoulos, A.; Rush, A. John

doi:10.1016/j.jad.2020.02.023

Cited by 177 publications

(166 citation statements)

References 144 publications

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“…Despite these available augmentation therapies, evidence on antidepressant combination therapies is limited (Bennabi et al 2019). Non-pharmacological treatment options for patients with TRD include cognitive behavioural therapy (CBT), vagus nerve stimulation, exercise (McAllister-Williams et al 2020), bright light therapy (Camardese et al 2015), electroconvulsive therapy and psychotherapy as combination therapies (Moret 2005). For example, a metaanalysis found that adjunctive CBT improved response compared with pharmacotherapy alone and sustained improvement for up to a year post-treatment (Li et al 2018).…”

Section: Considerations Prior To Initiating Treatment With Esketaminementioning

confidence: 99%

Practical recommendations for the management of treatment-resistant depression with esketamine nasal spray therapy: Basic science, evidence-based knowledge and expert guidance

Kasper

Cubała

Fagiolini

et al. 2020

The World Journal of Biological Psychiatry

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Objectives: Despite the available therapies for treatment-resistant depression (TRD), there are a limited number that are evidence-based and effective in this hard-to-treat population. Esketamine nasal spray, an intranasal N-methyl-D-aspartate (NMDA) glutamate receptor antagonist, is a novel, fast-acting option in this patient population. This manuscript provides expert guidance on the practicalities of using esketamine nasal spray. Methods: A group of six European experts in major depressive disorder (MDD) and TRD, with clinical experience of treating patients with esketamine nasal spray, first generated practical recommendations, before editing and voting on these to develop consensus statements during an online meeting. Results: The final consensus statements encompass not only pre-treatment considerations for patients with TRD, but also specific guidelines for clinicians to consider during and post-administration of esketamine nasal spray. Conclusions: Esketamine nasal spray is a novel, fast-acting agent that provides an additional treatment option for patients with TRD who have previously failed several therapies. The guidance here is based on the authors' experience and the available literature; however, further realworld use of esketamine nasal spray will add to existing knowledge. The recommendations offer practical guidance to clinicians who are unfamiliar with esketamine nasal spray.

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Section: Considerations Prior To Initiating Treatment With Esketaminementioning

confidence: 99%

Practical recommendations for the management of treatment-resistant depression with esketamine nasal spray therapy: Basic science, evidence-based knowledge and expert guidance

Kasper

Cubała

Fagiolini

et al. 2020

The World Journal of Biological Psychiatry

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“…1 Ketamine has primarily been used therapeutically in psychiatry for people experiencing depression that has proved difficult to treat, commonly referred to as treatment-resistant depression (TRD). 2,3 Reviews of single intravenous doses of ketamine in unipolar depression indicate that it can reduce depressive symptoms compared with either inert or active placebo, but the effects are transitory. 4,5 Individuals with TRD often experience suicidal thinking and have increased risk of suicidal acts.…”

Section: Ketamine For Treatment Of Depressionmentioning

confidence: 99%

Ketamine treatment for individuals with treatment-resistant depression: longitudinal qualitative interview study of patient experiences

et al. 2020

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Background Ketamine has recently received considerable attention regarding its antidepressant and anti-suicidal effects. Trials have generally focused on short-term effects of single intravenous infusions. Research on patient experiences is lacking. Aims To investigate the experiences over time of individuals receiving ketamine treatment in a routine clinic, including impacts on mood and suicidality. Method Twelve fee-paying patients with treatment-resistant depression (6 females, 6 males, age 21–70 years; 11 reporting suicidality and 6 reporting self-harm) who were assessed as eligible for ketamine treatment participated in up to three semi-structured interviews: before treatment started, a few weeks into treatment and ≥2 months later. Data were analysed thematically. Results Most participants hoped that ketamine would provide respite from their depression. Nearly all experienced improvement in mood following initial treatments, ranging from negligible to dramatic, and eight reported a reduction in suicidality. Improvements were transitory for most participants, although two experienced sustained consistent benefit and two had sustained but limited improvement. Some participants described hopelessness when treatment stopped working, paralleled by increased suicidal ideation for three participants. The transient nature and cost of treatment were problematic. Eleven participants experienced side-effects, which were significant for two participants. Suggestions for improving treatment included closer monitoring and adjunctive psychological therapy. Conclusions Ketamine treatment was generally experienced as effective in improving mood and reducing suicidal ideation in the short term, but the lack of longer-term benefit was challenging for participants, as was treatment cost. Informed consent procedures should refer to the possibilities of relapse and associated increased hopelessness and suicidality.

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“…In research, its definition is usually predicated on sequential pharmacotherapy, but no clear consensus exists regarding how best to capture true treatment resistance in clinical practice. Recently, alternative approaches have been proposed in an attempt to broaden the scope of the term, such as ‘difficult-to-treat depression’ (DTD), but even here the focus remains much the same, i.e., non-response (McAllister-Williams et al, 2020). Curiously, even though response refers to clinical improvement in the context of treatment, and a ‘failure to respond’ is clearly not a characteristic of the illness per se, the term is still often used to refer to the disorder as if it were a property of the underlying ‘disease’.…”

Section: Treatment-resistant Depressionmentioning

confidence: 99%

Channelling response: A novel perspective and therapeutic paradigm

Malhi

Bell

Boyce

et al. 2020

Aust N Z J Psychiatry

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Depression comprises heterogeneous syndromes with multifactorial aetiology that result in varied clinical manifestations. This makes its treatment challenging (Malhi and Mann, 2018). In addition to psychological, lifestyle and social interventions, the mainstay of management involves antidepressant pharmacotherapy. Worldwide, nearly 30 antidepressant medications are available that draw on a variety of putative mechanisms of action. However, clinically, relatively modest differences in efficacy separate these agents, and hence prescription choice is usually based on tolerability and clinician experience. In addition, several psychological interventions have replicated efficacy in clinical trials but again this is insufficient to differentiate individual therapies. In practice, approximately a third of depressed patients achieve remission in response to their first antidepressant treatment, and combining, augmenting or switching to another antidepressant is usually necessary to eventually attain remission in half of the remaining patients (Rush et al., 2006). This means that, overall, at least two-thirds of patients require several antidepressant trials to achieve remission, and, even then, many will need alternative treatments, such as psychosocial interventions or electroconvulsive therapy (ECT). In other words, despite the wide range of treatments available, poor response to antidepressants is common, and is once again attracting increasing attention.

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The identification, assessment and management of difficult-to-treat depression: An international consensus statement

Cited by 177 publications

References 144 publications

Practical recommendations for the management of treatment-resistant depression with esketamine nasal spray therapy: Basic science, evidence-based knowledge and expert guidance

Practical recommendations for the management of treatment-resistant depression with esketamine nasal spray therapy: Basic science, evidence-based knowledge and expert guidance

Ketamine treatment for individuals with treatment-resistant depression: longitudinal qualitative interview study of patient experiences

Channelling response: A novel perspective and therapeutic paradigm

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