Pharmacological treatment approaches
Pharmacological treatment approaches
It is widely accepted that at least one in three patients with depression will not respond adequately to a series of appropriate treatments.1 There have been several approaches to defining this difficult-to-treat depression.
One recently developed proposal is the Maudsley staging method — a points-based model of degrees of treatment resistance, which takes into account details of the specific treatments employed and the severity and duration of the depression.2 Another widely used and more straightforward definition is the failure to respond to two adequate trials of antidepressants from different pharmacological classes.3
Here, we use a pragmatic definition of difficult-to-treat depression — failure to respond to an adequate course of a selective serotonin reuptake inhibitor (SSRI) antidepressant. This was the definition used in the
Sequenced Treatment Alternatives to Relieve Depression
(STAR*D) trial in the United States,4 which was funded by the National Institute of Mental Health and is the single biggest study on sequenced treatment for depression and investigated rates of improvement in patients who had failed to respond to an SSRI. In this article, we draw liberally on the findings of the STAR*D trial, as well as other studies of difficult-to-treat depression.
STAR*D: a real-world study
The STAR*D trial used a series of treatment steps, premised on an initial failure to achieve remission after an adequate course of an SSRI. This approach reflects the reality of primary care and specialist treatment of depression in Australia (and most countries), whereby most patients who require antidepressants are initially treated with an SSRI. The trial recruited “real-world” patients with depression, including patients who are usually excluded from formal randomised controlled trials
(RCTs), such as those with chronic symptoms, comorbid psychiatric and physical disorders, and substance misuse.
It is widely accepted that at least one in three patients with depression will not respond adequately to a series of appropriate treatments.1 There have been several approaches to defining this difficult-to-treat depression.
One recently developed proposal is the Maudsley staging method — a points-based model of degrees of treatment resistance, which takes into account details of the specific treatments employed and the severity and duration of the depression.2 Another widely used and more straightforward definition is the failure to respond to two adequate trials of antidepressants from different pharmacological classes.3
Here, we use a pragmatic definition of difficult-to-treat depression — failure to respond to an adequate course of a selective serotonin reuptake inhibitor (SSRI) antidepressant. This was the definition used in the
Sequenced Treatment Alternatives to Relieve Depression
(STAR*D) trial in the United States,4 which was funded by the National Institute of Mental Health and is the single biggest study on sequenced treatment for depression and investigated rates of improvement in patients who had failed to respond to an SSRI. In this article, we draw liberally on the findings of the STAR*D trial, as well as other studies of difficult-to-treat depression.
STAR*D: a real-world study
The STAR*D trial used a series of treatment steps, premised on an initial failure to achieve remission after an adequate course of an SSRI. This approach reflects the reality of primary care and specialist treatment of depression in Australia (and most countries), whereby most patients who require antidepressants are initially treated with an SSRI. The trial recruited “real-world” patients with depression, including patients who are usually excluded from formal randomised controlled trials
(RCTs), such as those with chronic symptoms, comorbid psychiatric and physical disorders, and substance misuse.