Researchers outline clinical benefits of reconceptualizing treatment-resistant depression

Reconceptualizing treatment-resistant depression as difficult-to-treat depression may have implications for psychiatric research and practice, according to presenters at the American Society of Clinical Psychopharmacology Annual Meeting.

R. Hamish McAllister-Williams, MD, PhD, FRCPsych, of the Institute of Neuroscience at Newcastle University in the U.K., provided results of a consensus statement that defined difficult-to-treat depression as “depression that continues to cause a significant burden to the patient despite usual treatment efforts” and examined whether it may be a preferable clinical heuristic to treatment-resistant depression.

“The harder it is to treat an episode of depression, the more expensive it is to health care settings,” McAllister-Williams said during the virtual meeting. “Looking at the cost of inpatient, outpatient and pharmaceutical treatment for patients who have not responded to two, four, six or eight different treatments, the cost goes up with each failed treatment or each pair of failed treatments. We are going to be using cheaper medications and simpler-to-use treatments for first-line treatment. [If a patient] becomes less responsive, we're going to be more likely to use less readily available and more expensive interventions.”

Patients with difficult-to-treat depression have 30% higher mortality rates than those without this form of depression, which makes aiming for remission as the target of standard treatment conceptualization important, according to McAllister-Williams.

Augustus Rush, MD, of the National University of Singapore, and colleagues put forth the notion of difficult-to-treat depression, McAllister-Williams said, because it semantically shifts the onus from the patient compared with treatment-resistant depression, as well as takes a chronic illness approach.

“Treatment-resistant depression focuses on further acute treatments, whereas difficult-to-treat depression thinks about reevaluating why the individual patient has this form of depression and what makes it difficult to treat,” McAllister-Williams said. “The approach then says, ‘Are any of those reasons tractable? Can we do something to make this depression less difficult to treat, and therefore have an improvement in symptoms and overall focus on improvements in psychosocial function and management?’”

McAllister-Williams said the management of difficult-to-treat depression includes the following steps:

• identification through a series of routine assessments;

• reconsideration of differential diagnosis;

• identification and treatment of any comorbidities;

• identification of the predisposing, precipitating and perpetuating factors related to the patient's individual depression; and

• implementation of steps to address difficult-to-treat depression into practice, including achieving optimal symptom control and targeting symptoms associated with poor outcomes.

Unmet research needs exist regarding difficult-to-treat depression, according to Rush.

“One big question that we don't [have the answer to] is, ‘What is the actual prevalence of suspected difficult-to-treat depression?’” Rush said. “One of the reasons we don't know that is that our practice variation is extremely high. The sources of entry into treatment are multiple, from medical to psychological to spiritual, etc., so we don't really have a good sense of how many people have medically diagnoseable and medically treatable conditions that appear to be difficult to treat among well-treated individuals where adherence and poor treatment delivery is not an issue.” – by Joe Gramigna

Reference:

McAllister-Williams, et al. Difficult-to-treat depression: What are the implications for research and practice? Presented at: American Society of Clinical Psychopharmacology Annual Meeting; May 29-30, 2020 (virtual meeting).

Disclosures: McAllister-Williams reports he serves as an advisory board member and research grant principal investigator for, as well as receives honoraria from, Livanova; receives honoraria from Lundbeck; and serves as an advisory board member for Janssen. Rush reports he receives consulting fees from eight pharmaceutical companies; royalties from Guilford Press and University of Texas Southwestern Medical Center; and has two patents.