Psychiatric Annals

Editorial 

Lessons from Treatment-resistant Depression

Jan Fawcett, MD

Abstract

This issue of Psychiatric Annals is focused on bipolar and treatment-resistant depression and features articles based on presentations from the third annual Psychiatric Annals Symposium, which was held in New York in late March of this year. We hope you'll join us for our fourth annual Symposium, March 24–26, 2006, which will focus on targeted treatment regimens. For more information and registration, see the ad on pages 954–955 of this issue.

Treatment-resistant depression varies in its definition, but no one disagrees that it is a prevalent problem that results in persistent pain, disability, broken relationships, and sometimes suicide for our patients who suffer from this condition. There are a number of lessons to be learned when dealing with treatment-resistant or treatment-refractory depression. The first lesson is that one cannot predict what treatment a patient may benefit from. Despite the failure of one medication, the patient may respond to a medication similar to it.

For example, I have seen patients that failed to respond to nortripty-line at therapeutic doses go into remission on amitriptyline after failed trials on several selective serotonin reuptake inhibitors and selective norepinephrine reuptake inhibitors. Another example would be a patient with a 4-year depression with a recurrence after 2 years taking 120 mg of phenelezine, 40 mg of dextroamphetamine, and 20 mg of olanzapine who is unresponsive to 14 sessions of electroconvulsive therapy, develops orthostatic hypotension on 40 mg of isocarboxyzid, and then finally responds with a full remission to 50 mg of isocarboxyzid, 20 mg of dextroamphetamine, and 600 mg of quetiapine. Is that a predictable response?

The next lesson resulting from working with treatment-resistant depression is that one should never give up trying to find a regimen that will help the patient. The treatments we have available are of limited effectiveness. Combinations and augmentations often are necessary to obtain a satisfactory response or remission. One cannot predict what might help the patient, but continued efforts increase the patient's chances until we have better treatment.

The issue leads off with “The 'Treatment-resistant' Label in Bipolar Disorder is a Misnomer” by Dr. Max Fink, who gives an in-depth look at the efficacy of electroconvulsive therapy for depression in bipolar disorder, as well as barriers to its use. As Dr. Fink writes, “We are not so rich in effective treatments for bipolar disorder that we can arbitrarily reject an effective treatment, no matter how it is stigmatized.”

Pharmacologic options for the management of treatment-resistant or treatment-refractory depressive states are discussed in the remainder of the issue. In his article “Pharmacologic Strategies for Treatment-resistant Depression: An Update on the State of the Evidence,” Dr. Michael Thase gives an overview of the available treatment options and the research to back them up, emphasizing the need for continuing clinical studies to support current treatments and introduce new alternatives. In “Therapeutic Challenge: Antidepressant Monotherapy of Major Depressive Episodes in Bipolar II Disorder,” Dr. Jay Amsterdam and colleagues review common therapeutic choices and discuss clinical research regarding the use of specific medications for the management of depression in bipolar disorder. Finally, Drs. Zajecka and Goldstein focus on the use of polypharmaceutical treatments in their article “Combining and Augmenting: Choosing the Right Therapies for Treatment-resistant Depression.”

It appears that another year is almost gone by. It's coming up on a time to evaluate how we spent the past year and how we might better spend our precious time in 2006. Did I live my life with enough meaning, did I help others enough, did I use the precious time in the most effective way to make it count? How can I use my time…

This issue of Psychiatric Annals is focused on bipolar and treatment-resistant depression and features articles based on presentations from the third annual Psychiatric Annals Symposium, which was held in New York in late March of this year. We hope you'll join us for our fourth annual Symposium, March 24–26, 2006, which will focus on targeted treatment regimens. For more information and registration, see the ad on pages 954–955 of this issue.

Treatment-resistant depression varies in its definition, but no one disagrees that it is a prevalent problem that results in persistent pain, disability, broken relationships, and sometimes suicide for our patients who suffer from this condition. There are a number of lessons to be learned when dealing with treatment-resistant or treatment-refractory depression. The first lesson is that one cannot predict what treatment a patient may benefit from. Despite the failure of one medication, the patient may respond to a medication similar to it.

For example, I have seen patients that failed to respond to nortripty-line at therapeutic doses go into remission on amitriptyline after failed trials on several selective serotonin reuptake inhibitors and selective norepinephrine reuptake inhibitors. Another example would be a patient with a 4-year depression with a recurrence after 2 years taking 120 mg of phenelezine, 40 mg of dextroamphetamine, and 20 mg of olanzapine who is unresponsive to 14 sessions of electroconvulsive therapy, develops orthostatic hypotension on 40 mg of isocarboxyzid, and then finally responds with a full remission to 50 mg of isocarboxyzid, 20 mg of dextroamphetamine, and 600 mg of quetiapine. Is that a predictable response?

The next lesson resulting from working with treatment-resistant depression is that one should never give up trying to find a regimen that will help the patient. The treatments we have available are of limited effectiveness. Combinations and augmentations often are necessary to obtain a satisfactory response or remission. One cannot predict what might help the patient, but continued efforts increase the patient's chances until we have better treatment.

In This Issue

The issue leads off with “The 'Treatment-resistant' Label in Bipolar Disorder is a Misnomer” by Dr. Max Fink, who gives an in-depth look at the efficacy of electroconvulsive therapy for depression in bipolar disorder, as well as barriers to its use. As Dr. Fink writes, “We are not so rich in effective treatments for bipolar disorder that we can arbitrarily reject an effective treatment, no matter how it is stigmatized.”

Pharmacologic options for the management of treatment-resistant or treatment-refractory depressive states are discussed in the remainder of the issue. In his article “Pharmacologic Strategies for Treatment-resistant Depression: An Update on the State of the Evidence,” Dr. Michael Thase gives an overview of the available treatment options and the research to back them up, emphasizing the need for continuing clinical studies to support current treatments and introduce new alternatives. In “Therapeutic Challenge: Antidepressant Monotherapy of Major Depressive Episodes in Bipolar II Disorder,” Dr. Jay Amsterdam and colleagues review common therapeutic choices and discuss clinical research regarding the use of specific medications for the management of depression in bipolar disorder. Finally, Drs. Zajecka and Goldstein focus on the use of polypharmaceutical treatments in their article “Combining and Augmenting: Choosing the Right Therapies for Treatment-resistant Depression.”

Looking Ahead

It appears that another year is almost gone by. It's coming up on a time to evaluate how we spent the past year and how we might better spend our precious time in 2006. Did I live my life with enough meaning, did I help others enough, did I use the precious time in the most effective way to make it count? How can I use my time and direct my efforts and intentions to make next year even better? Am I appreciating the loving relationships available to me, the beauty around me, the opportunities to be of help to others, or am I getting caught up in a rat race, living robotically and letting my precious life space evaporate? Am I devoting enough time and attention to my creative imagination, to finding the spark of divinity in myself and others, even if they are unaware of it?

Personally, I am hooked on the experience of seeing severely depressed patients recover and get back their lives. That's why I can't give up my clinical work. Here's to happy, loving holidays and a creative, healthy, meaningful, appreciative, and aware New Year for all.

Authors

10.3928/00485713-20051201-01

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