[How to treat and manage unsatisfactory response?]

Area of Science:

• Neuroscience
• Psychiatry
• Pharmacology

Background:

• First-line depression treatments are effective for only one-third of patients.
• Over half of patients experience less than a 50% symptom reduction after three months.

Purpose of the Study:

• To review scientific evidence for therapeutic strategies following first-line treatment failure in depression.
• To guide clinical decisions for managing treatment-resistant depression.

Main Methods:

• Review of pharmacological strategies: dose optimization, drug switching, and combination/potentiation therapies.
• Evaluation of non-pharmacological options: psychotherapy, physical exercise, and neuromodulation techniques (rTMS, ECT).
• Analysis of recent French and international treatment guidelines.

Main Results:

• Pharmacological options include adjusting dosages, switching antidepressants (inter- or intra-class), or combining/potentiating with other drugs (e.g., lithium, atypical antipsychotics).
• Psychotherapy, particularly cognitive-behavioral and interpersonal therapies, shows efficacy comparable to pharmacological treatments.
• Neuromodulation techniques like repetitive transcranial magnetic stimulation (rTMS) and electroconvulsive therapy (ECT) are effective, with ECT being the most potent for severe or resistant cases.

Conclusions:

• Multiple strategies exist for managing depression treatment failure, including optimizing current medication, switching to alternatives, or employing combination therapies.
• Psychotherapy and neuromodulation offer viable alternatives or adjuncts to pharmacotherapy.
• Earlier consideration of potent therapies like ECT may be beneficial for chronic or resistant depression.