Depression Symptoms Treatment

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More than 20% of patients with major depression have not recovered after 2 years and, of those who do initially recover, 20% suffer a relapse 1 year later. Most studies have shown that 60% to 70% of patients respond to the first antidepressant used and a further 10% to 15% respond either to a second antidepressant or to electroconvulsive therapy (ECT). About 15% of patients fail to recover even with multiple therapeutic trials and can be called treatment resistant. However, even these patients can be helped by supportive psychotherapy and lifestyle changes. The terms absolute and relative are used to describe treatment-resistant depression (TRD). Patients with absolute TRD have been correctly diagnosed, have received adequate treatment, but have failed to improve. Patients with relative treatment-resistant depression (TRD) have not been adequately assessed, have not received adequate treatment, or have reached the limit of the expertise of their attending physicians.

Factors involved in treatment failure

Several questions should be considered when assessing patients with mood disorders who have not responded to treatment (Table 1).

Is the diagnosis correct?

Several psychiatric illnesses present with depressive symptoms or with comorbid or secondary depression and are mistakenly diagnosed as a primary depression. These include obsessive compulsive disorder; panic disorder or generalized anxiety disorder with demoralization; posttraumatic stress disorder, particularly in adults who have been sexually abused as children; schizophrenic defect state with apathy; uncomplicated grief; and dementia, such as early Alzheimer’s disease with cognitive decline. Although anti-depressants might benefit some of these patients, the treatment approach to each of these disorders is quite different.

Can the depression be subtyped?

For several subtypes of depression, a standard approach to treatment likely will be ineffective, and patients will appear treatment resistant. More information on these subtypes is available elsewhere.

Bipolar affective disorder, depressed phase

The depressed phase of bipolar disorder clinically resembles an episode of major depression. Introducing lithium or other anticycling drugs and avoiding drugs that might induce cycling becomes important. Rapid onset of symptoms, hypersomnia, a postpartum trigger, a history of manic or hypomanic episodes, or a positive family history are clues to bipolarity.

Delusional (psychotic) depression

A major depressive episode with psychotic features, such as mood-congruent delusions or auditory hallucinations, usually responds poorly to antidepressant monotherapy and requires an antipsychotic agent as well. Electroconvulsive therapy, however, is the treatment of choice.

Major depression with obsessional features

Major depression presenting clinically with obsessions and compulsions responds better to antidepressants that are strong inhibitors of the serotonin transport system, such as the tricyclic clomipramine or any of the selective serotonin reuptake inhibitors (SSRIs).

Atypical depression

Atypical depression is characterized by symptoms such as panic attacks, severe generalized anxiety, agoraphobia, or social phobia. Vegetative features are also atypical and include initial insomnia, increased appetite, hypersensitivity to rejection, and attention-seeking behaviours. Monoamine oxidase inhibitors (MAOIs) or the reversible inhibitors of monoamine oxidase A (RIMA) are probably the agents of choice.

Postpartum depression

About 80% of depressions that begin for the first time postpartum are bipolar. Postpartum depression often resists treatment. Psychosocial issues, such as bonding with the infant and the marital relationship, are very important and need to be addressed as part of the treatment plan. If the mother is hospitalized, physicians should consider admitting the infant once the mother has improved enough to show interest in and look after the baby, even if assistance from nursing staff is needed.

Double depression

Double depression, as the name suggests, is a major depression superimposed on chronic dysthymia. Chronic dysthymia usually requires psychotherapy and lifestyle changes, although pharmacotherapy can help. A major depression that responds to antidepressants might seem unresolved if the dysthymia continues untreated.

Seasonal affective disorder

In this disorder, probably a variant of bipolar disorder, patients suffer from a winter-onset depression for at least 2 consecutive years and have either a normal mood or mild hypomania during the summer. Seasonal affective disorder (SAD) is further characterized by carbohydrate craving, decreased energy, and increased need for sleep during the winter depressive phases. Some patients with SAD respond to traditional antidepressants or lithium, but the treatment that seems most effective is light therapy. Patients with variants of seasonal affective disorder (SAD), such as summer depression (and winter highs), sometimes respond to temperature manipulation rather than light.