Current perspectives in the management of treatment-resistant depression

Depressive disorders are a leading cause of disability worldwide and greatly impact morbidity, health care utilization, and medical costs. Major depression that does not resolve with adequate antidepressant treatment is termed treatment-resistant depression (TRD), There is no universally accepted definition of TRD and several criteria have been suggested to define it. Multiple factors can contribute to treatment resistance, including unrecognized comorbid medical or psychiatric illness, the use of concomitant medications, noncompliance, and psychosocial stressors. TRD is associated with extensive use of depression-related and general medical services, and poses a substantial economic burden. Current approaches to its management include the use of antidepressant strategies, such as increasing the dose of the antidepressant, augmentation strategies, combination strategies, and switching strategies, electroconvulsive therapy, and cognitive behavioral therapy. Although no definite algorithm exists for treating TRD, research in this area has advanced considerably in recent years. One approach to this is a clinical trial called STAR*D (Sequenced Treatment Alternatives to Relieve Depression). This has the potential to increase our understanding about the diagnostic and therapeutic aspects of TRD, to substantially reduce disability, and to enhance the quality of life in individuals with this condition.