Treating stubborn depression

Depression can be a stubborn problem—at least one in three patients fail to respond to proven therapies—and experts in the field have put their heads together to outline practical treatment approaches for general practitioners in an MJA Open supplement on "difficult-to-treat depression". "While GPs have many skills in the assessment and treatment of depression, they are often faced with people with depression who simply do not get better, despite the use of proven therapies, be they psychological or pharmacological", wrote Professor David Castle, Chair of Psychiatry at St Vincent's Health and the University of Melbourne, and coauthors.

They wrote that they hoped the approaches outlined in the supplement could assist clinicians—and GPs in particular—to improve the outcomes of patients with difficult-to-treat depression. In an article on pharmacological approaches to the problem, Dr Herng-Nieng Chan and Professor Philip Mitchell, psychiatrists with the University of New South Wales and the Black Dog Institute, and coauthors outlined the latest evidence-based drug treatment strategies for people with difficult-to-treat depression, based on studies including a US trial of almost 3000 patients.

The US study found that 30% of patients failed to achieve remission of their depression after using up to four different antidepressants. "This finding reflects the reality of clinical practice and highlights the need to employ the best available evidence in the management of people with complex depression", they wrote.

Professor Paul Fitzgerald, a psychiatrist from Monash Alfred Psychiatry Research Centre, wrote that electroconvulsive therapy remained the most widely used and effective biological non-drug treatment for difficult-to-treat depression.

However, he also detailed innovative new forms of brain stimulation, including magnetic seizure therapy and vagus nerve stimulation, which showed promise. "Ongoing work is required to define which treatments are likely to be most useful, and in which patient groups", he wrote.

Dr Melissa Casey, director of psychology at Southern Health, and coauthors wrote that evidencebased psychological approaches including cognitive behaviour therapy, interpersonal psychotherapy and family-based therapy could improve outcomes in difficult-to-treat depression.

As thought patterns and behaviour played a large role in determining outcomes of treatment for people with depression, they wrote, they were "prime candidates for intervention through a psychosocial treatment regimen".

Provided by University of New South Wales