Consider Psychotherapy in Resistant Depression. (Sooner Rather Than Later)

Article excerpt

CHICAGO -- An integrative approach is called for in working with depressed patients who fail to respond adequately to medication, Dr. Mantosh J. Dewan said at the American Psychiatric Association's Institute on Psychiatric Services.

Clinicians should think of psychotherapy (perhaps as an augmentation strategy) sooner rather than later. In addition, they should keep in mind that medical conditions--including some common nutritional deficiencies--may play a role in treatment resistance, said Dr. Dewan, chair of psychiatry at the State University of New York, Syracuse.

"For difficult-to-treat patients, it makes sense to add psychotherapy rather than endless polypharmacy. That's where the data are ... you address different systems and aspects of function," he said.

The notion that many depressed patients respond suboptimally to initial therapy is well known. Just one-third achieve remission with a first selective serotonin reuptake inhibitor, and improvement in 10%-15% more is significant but falls short of remission.

The standard strategies in such cases are optimizing the dose and duration of the starting drug, switching to another antidepressant (especially if there has been no response), or--particularly if the initial response is reasonably robust--adding lithium, thyroid hormone, a less tested augmentation agent, or a second antidepressant.

Some algorithms call for adding third and even fourth medications if the response remains unsatisfactory. But relatively early in the process, factors that may underlie nonresponse should be considered, particularly cormorbidity, he said.

This calls for a thorough medical evaluation. Nearly two-thirds of depressed patients have concurrent medical conditions and some--including endocrine disorders, infections, neurologic disorders such as complex partial seizures--may contribute to treatment resistance. …