Treatment Resistant Depression— Advances in Somatic Therapies
University Health Network and University of Toronto, Toronto, Ontario, Canada. Annals of Clinical Psychiatry
(Impact Factor: 2.36).
10/2007; 19(4):279-87. DOI: 10.1080/10401230701675222
The failure to achieve remission for patients with Major Depressive Disorder (MDD) represents a major public health concern. Inadequately treated depression is associated with higher rates of relapse, poorer quality of life, deleterious personal and societal economic ramifications, as well as increased mortality rates. Unfortunately, only a minority of patients achieves this goal with initial antidepressant treatment and by convention, failure to achieve response after two adequate trials of antidepressant therapy defines "Treatment Resistant Depression" (TRD). Furthermore, results from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) group of studies suggest that approximately 50% of "real world" patients who meet criteria for MDD fail to achieve remission, even after four carefully monitored sequenced treatments.
Given these limitations of existing antidepressant medications alone and in combination, together with improved understanding of the neural circuitry of depression, it is not surprising that there is a renewed interest in neuromodulation strategies for TRD.
The purpose of this article is to review the evidence for the inclusion of various non-pharmacological, neuromodulatory strategies for TRD. Specifically, information regarding the mechanism, tolerability and efficacy of electroconvulsive therapy (ECT), magnetic seizure therapy (MST), repetitive transcranial magnetic stimulation (rTMS), vagal nerve stimulation (VNS), and deep brain stimulation (DBS) in ameliorating TRD will be presented.
Although these treatments are at various stages of clinical development, they represent a new frontier in expanding the treatment options available for individuals with TRD, as well as contributing to a better understanding the neurobiology of depressive disorders.
Available from: Amer Burhan
- "ECT is used in treatment resistant depression, which has been defined in several ways, but the generally accepted definition is failure to respond to successive adequate trials (dose and duration) of two antidepressants from different classes. Although initially it was estimated that 15-20% of patients with depression fall into the category of treatment resistant depression, the STAR-D naturalistic trial showed a rate as high as 50 % . In treatment resistant depression, ECT provides fair efficacy and can help more than half of these patients     . "
- "With regard to somatic treatments, only a moderate percentage of patients were found to gain relief with deep brain stimulation techniques, but results should not be generalized as sample sizes are small and a robust research methodology is needed (Kennedy & Giacobbe, 2007). Repetitive transcranial magnetic stimulation (rTMS) appears to provide significant benefits in short-term treatment studies. "
Available from: Leticia Cuellar-Pompa
- "It is also important to develop a standardized, operational definition of TRD to facilitate comparisons across studies (McPherson et al., 2005). Although it was not the main aim of this research, this systematic review revealed, in line with many research studies (e.g., Bschor & Bauer, 2006; Catafau et al., 2001; Kennedy & Giacobbe, 2007; O'Reardon, Thase, & Papakostas , 2009), a considerable heterogeneity regarding most conceptual and methodological issues involved in the ascertainment of TRD in the published literature. More specifically , there are major differences in the number and type of previous failed trials required to make a diagnosis of TRD, the definition of treatment adequacy (dose, titration, and duration) and treatment response, and the assessment of primary and comorbid diagnoses. "
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ABSTRACT: The objective of this research study was to assess pharmacological, somatic and/or
psychological treatments in adults with a diagnosis of major depressive disorder who have not
responded to at least one course of antidepressant medication. We conducted a systematic
review to identify systematic scientific reviews and meta-analyses on treatment-resistant
depression (TRD) published until February 2012. Of the sixty studies selected, sixteen met the
inclusion criteria and were therefore included in the review. We considered eight main themes,
including the definition of TRD, long-term results, and different treatment strategies, including
so-called somatic therapies. Based on the review, the definition of TRD should be standardized
in order to achieve a shared conceptualization of this disorder. This would allow a better
understanding among clinicians and researchers in the field, promoting a homogeneous research
methodology and thus leading to more reliable and comparable results. This essential conceptual
clarification would also have a positive impact on patients with TRD, their families, and social
and health systems.
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