Resistant depression

This term covers patients with significant depressive illness who do not seem to respond to standard treatment, or respond only partially. Recovery, or at any rate improvement, is possible with continued treatment in most cases. Probably, combinations of medication, such as antidepressants with a small dose of a major tranquillizer or a mood stabilizer will need to be tried. The following points need to be considered:

• Reassess the diagnosis, excluding underlying physical pathology.

• Are social/family problems perpetuating the illness?

• Could cognitive therapy help habitual negative thinking patterns?

• Has the patient actually taken the medication?

• Have adequate doses have been given for long enough?

• Consider change of antidepressant class (tricyclic/MAOI/SSRI).

• Consider adding an 'adjuvant' such as lithium or an alternative mood stabilizer.

• Other 'adjuvant' drugs such as a small dose of an antipsychotic drug can be considered.

• Thyroid treatment can be tried, even if the patient is not hypothyroid; for example, liothyronine is used.

• Combination antidepressant treatment (tricyclic plus SSRI) is not infrequently tried. The use of combinations of tricyclic and MAOI is now very unusual, and requires specialist supervision.

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