The management of treatment-resistant depression in the medically ill.

There are a few well-designed studies to systematically assess treatment-resistant depression in the medically ill patient. Psychiatrists, however, do have extensive clinical experience in treating depression in the medical patient. This experience can be useful in helping to determine treatment resistance and in selecting consequent treatment choices. A decision tree is offered in Table 1 to clarify the questions the clinician must answer. The first step is to evaluate the role of the medical illness and to decide whether or not treating that effectively will also clear the depression. Physicians may find it helpful to use a decision tree in initiating treatment of patients with depression and physical illness. Once it has been clarified that the diagnosis of depression is a correct one and that an antidepressant medication is in order, consideration of safety, side effects, and other current prescriptions used by the patient must occur. Drug-drug interactions as well as changes in the clearance of medications are critical to the effectiveness of the choice and tolerability for the patient. An antidepressant agent needs to be given for an adequate time with optimization of dosing. Augmenting a medication to increase its therapeutic action could be tried if one agent alone is not effective. An alternative approach is that the second drug selected might affect different neurotransmitters, and the combination of mechanisms would result in resolution of symptoms. Adding psychotherapy, especially when social supports are lacking, can be particularly helpful. ECT is an important consideration for severe depression when suicidal concerns are imminent or the patient has not responded to pharmacotherapy trials. While we await further studies of treatment-resistant depression in large enough numbers of patients with particular illnesses, we can use these guidelines to direct our decisions to switch or augment our initial choices to provide the safest, most effective care possible.