[Treatment of a refractory depressive episode]

In treating refractory depression, we have, firstly, to search for some factors, known to be associated with resistance, like somatic illnesses or drugs which induce depression. In a second time, it is necessary to distinguish refractory depression from insufficiently treated depression. For this purpose: does the treatment fit to the subtype of depression to be treated? Is the dosage of antidepressant sufficient? is the duration of treatment trial long enough? Some strategies can be used to treat resistant depressive patients. Mono Amine Oxidase Inhibitors (MAOIs) seem to be sometimes very efficient in the treatment of refractory depressives. In some cases, it is necessary to prescribe high dosages of such drugs or to use them in association with tricyclic antidepressants. It must be emphasized that such associations are sometimes dangerous and must be used cautiously. Selective Serotonin Reuptake Inhibitors (SSRIs) seem to be characterized by a different spectrum of effects than tricyclics. This specificity could be useful in treating refractory depression; ECT are often efficient in such patients and must be done if antidepressants fall to improve the disorder. Adjunction of lithium to antidepressant regimen is efficient in many cases and well documented since a few years. This association is efficacious in almost 30% of refractory depressive disorders. In some cases, adjunctive lithium leeds to improvement of depressive symptoms very quickly, in 2 or 3 days. In other cases, onset of improvement occurs only after the usual time of 2 to 3 weeks. The adjunction of triiodothyronine (T3) to antidepressants is sometimes efficacious and raises some questions about the thyroïd axis function in depressives.(ABSTRACT TRUNCATED AT 250 WORDS)