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Defining and Assessing Treatment-Resistant Depression Prof. Philip Cowen Professor of Psychopharmacology Department of Psychiatry University of Oxford, UK

Defining treatment-resistant depression

Definition: industry trials Failure to respond to two separate antidepressant trials

Assessing treatment-resistant depression

In practice: individual assessment Treatment history: Number of medications Psychological treatments Course: how long the condition has been going on Impingement on coping resources Symptomatology level Disability Ability to work Social life Level of treatment resistance

In practice: individual assessment Treatment history: Number of medications Psychological treatments Course: how long the condition has been going on Impingement on coping resources Symptomatology level Disability Ability to work Social life Level of treatment resistance

In practice: individual assessment Treatment history: Number of medications Psychological treatments Course: how long the condition has been going on Impingement on coping resources Symptomatology level Disability Ability to work Social life Level of treatment resistance

In practice: individual assessment Treatment history: Number of medications Psychological treatments Course: how long the condition has been going on Impingement on coping resources Symptomatology level Disability Ability to work Social life Level of treatment resistance

Bipolar spectrum conditions Is it major depression? Diagnostic aspects Comorbid anxiety Substance abuse Comorbidities Standard antidepressant treatment: not as effective Bipolar spectrum conditions

Bipolar spectrum conditions Is it major depression? Diagnostic aspects Comorbid anxiety Substance abuse Comorbidities Standard antidepressant treatment: not as effective Bipolar spectrum conditions Vázquez GH, Tondo L, Undurraga J, et al (2014) Pharmacological treatment of bipolar depression. Advances in Psychiatric Treatment, 20: 193–201.

Negative thinking vs psychotic symptom Depressive psychosis Negative thinking vs psychotic symptom Antidepressant monotherapy Rarely successful Antipsychotic drug fully dosed As if treating a psychosis Good response

Negative thinking vs psychotic symptom Depressive psychosis Negative thinking vs psychotic symptom Antidepressant monotherapy Rarely successful Antipsychotic drug fully dosed As if treating a psychosis Good response Wijkstra J, Burger H, Van den Broek WW, et al (2010) Treatment of unipolar psychotic depression: a randomized, double-blind study comparing imipramine, venlafaxine, and venlafaxine plus quetiapine.Acta Psychiatrica Scandinavica, 121: 190–200.

Negative thinking vs psychotic symptom Depressive psychosis Negative thinking vs psychotic symptom Antidepressant monotherapy Rarely successful Antipsychotic drug fully dosed As if treating a psychosis Good response Wijkstra J, Burger H, Van den Broek WW, et al (2010) Treatment of unipolar psychotic depression: a randomized, double-blind study comparing imipramine, venlafaxine, and venlafaxine plus quetiapine.Acta Psychiatrica Scandinavica, 121: 190–200.

Key points Consider differential diagnoses: Psychotic disorders, bipolar spectrum conditions, substance misuse and eating disorders If you do not see any response after 4 weeks: Unlikely the patient will improve with that medication

Key points Consider differential diagnoses: Psychotic disorders, bipolar spectrum conditions, substance misuse and eating disorders If you do not see any response after 4 weeks: Unlikely the patient will improve with that medication

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