When should you, the prescriber, conclude that your patient with depression is “treatment resistant,” and thereby eligible for alternative non-pharmacological interventions—such as vagus nerve stimulation (VNS), electroconvulsive therapy (ECT), or transcranial magnetic stimulation (TMS)?

There are multiple ways that the failure to agree on a standardized definition of treatment-resistant depression (TRD) impacts the clinical care of patients who do not respond to multiple medication trials. In an article appearing in the January 2017 issue of JAMA Psychiatry, Charles Conway, M.D., Mark George, M.D., and Harold Sackheim, Ph.D., wrote that the lack of a consensus definition around what constitutes TRD “limits the ability to do comparative treatment research, to understand the biological underpinnings of TRD, and produces ambiguous medical insurance coverage issues.”

Drawing on data from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, they proposed a definition for TRD: failure to respond to two trials of an antidepressant prescribed at an adequate dose for an adequate duration of time.

Conway, a professor of psychiatry and director of the Treatment Resistant Depression and Neurostimulation Clinic at Washington University, St. Louis, said that in the absence of a consensus definition of TRD, patients often receive multiple trials of medication. “Our experience has been that when faced with patients who do not respond to a series of medications, clinicians typically continue to give more similar medications, despite there being no evidence to support that the 5th or 6th medication will work,” he told Psychiatric News.

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