Approaches to the treatment of refractory depression

The authors first discuss the incidence and characteristics of refractory depression. They outline questions clinicians should ask when a depressed patient does not respond to an antidepressant (e.g., about the adequacy of the trial; the patient's compliance with medication; comorbid medical illnesses or substance abuse; other medications the patient is taking; the correctness of the diagnosis; the presence of psychotic features, bipolar illness, or recurrent brief depression; family issues; and the nature of the doctor-patient relationship). A general approach to the treatment of refractory depression is then given, including dealing with comorbid substance abuse, family issues, and psychological factors that may be complicating treatment. The authors review specific treatment strategies for refractory unipolar depression, including dosage adjustments, augmentation strategies, changing or combining antidepressants, and electroconvulsive therapy (ECT). They then discuss strategies for treating refractory bipolar depression, including the cautious use of antidepressants, the use of one or more mood stabilizers, augmentation strategies, and ECT. The article concludes with a discussion of the need for maintenance therapy in refractory depression.