Section - Video Lectures

11. Treatment-Resistant Depression Without Comorbidity: Treatment Options (Node 5)

Published on November 2, 2019 Expired on March 31, 2022

David Osser, M.D.

Associate Professor of Psychiatry - Harvard Medical School

Key Points

For depression resistant to 2 treatments, first reevaluate diagnosis, and then look again into psychosocial and other factors that may be fueling the resistance, such as dyadic discord. Next, determine if the patient has 1 of 4 comorbidities that could lead to special recommendations at this point. These comorbidities include chronic pain, OCD, ADHD, and PTSD. If present, see Video 12 of this lecture, where this will be reviewed.
If no comorbidity exists, see if the patient meets criteria for the atypical features specifier ([AFS] i.e., mood reactivity plus 2 of the following: Overeating, oversleeping, leaden paralysis, and rejection sensitivity trait).
If the AFS is present, consider trying an MAOI, like selegiline or phenelzine, or an SSRI plus aripiprazole. If the AFS is not present, see if the patient wants an augmentation or a switch. See Videos 9 and 10 for these options.
Additional options include a tricyclic, the combination of venlafaxine and mirtazapine, or ECT.

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Slides and Transcript

Slide 1 of 12

This is video 11 of the Algorithm for the Psychopharmacology of Major Depression from the Harvard South Shore Psychopharmacology Algorithm Project. In this video, we discuss treatment-resistant depression.

Treatment-Resistant Depression Without Comorbidity: Treatment Options (Node 5) Slide 1 of 12

Slide 2 of 12

The patient has already had two adequate trials or a trial plus an augmentation to treat this depression which we have already excluded various comorbidities and other factors. So this is a relatively standard case of major depression and yet the patient has failed two trials. We define that as treatment-resistant depression. There are many different definitions of treatment-resistant depression but that’s how we define it here, two adequate trials according to the sequence that we think is best, most evidence based and supported by the patient. STAR*D and other evidence suggest that the expectations of success with further trials are greatly diminished compared to these first two trials. And furthermore, even if the patient does remit on the next trial or trials, the chances of relapse in the next year are up to 70% or more, 65% after three failed trials.

References:

Rush, A. J., Trivedi, M. H., Stewart, J. W., Nierenberg, A. A., Fava, M., Kurian, B. T., … & Cook, I. A. (2011). Combining medications to enhance depression outcomes (CO-MED): acute and long-term outcomes of a single-blind randomized study. American Journal of Psychiatry, 168(7), 689-701.
Trivedi, M. H., Fava, M., Wisniewski, S. R., Thase, M. E., Quitkin, F., Warden, D., … & Luther, J. F. (2006). Medication augmentation after the failure of SSRIs for depression. New England Journal of Medicine, 354(12), 1243-1252.

Treatment-Resistant Depression Without Comorbidity: Treatment Options (Node 5) Slide 2 of 12

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12. Treatment-Resistant Depression With Comorbidity: Chronic Pain, OCD, ADHD, and PTSD (Node 6)