A proposed clinical approach to chronic and "resistant" depressions: evaluation and treatment

Many patients referred to specialized affective disorder units in the 1970s because of chronicity, treatment resistance, or treatment failure were found to have been inadequately treated--most typically with suboptimal trials of one to two tricyclic antidepressants (TCAs). In the 1980s, patients are being declared "treatment failures" following a more sophisticated range of treatment efforts. In part, the change can be attributed to systematic feedback provided by mood clinics to referring clinicians and to nationwide educational efforts. Terminologic and conceptual issues are reviewed, and chronicity and treatment failure in patients with affective disorders are examined from a multifactorial perspective involving pharmacokinetic factors, patient compliance, adequacy of somatic treatments, physician countertransference, social and interpersonal aspects, nosologic considerations, and medical-neurologic contributions. A systematic approach for evaluating and treating such patients is outlined.