Efficacy and acceptability of adjunctive psychological and pharmacological interventions for treatment-resistant depression: protocol for a systematic review and network meta-analysis

Treatment resistant depression in elderly

Treatment refractory depression (TRD) in the elderly is a common psychiatric disorder with high comorbidity and mortality. Older adults with TRD often have complicated comorbidities and several predisposing risk factors, which may lead to neuropsychiatric dysfunction and poor response to treatment. Several hypotheses suggest the underlying mechanisms, including vascular, immunological, senescence, or abnormal protein deposition. Treatment strategies for TRD include optimization of current medication dose, augmentation, switching to an alternative agent or class, and combination of different antidepressant classes, as well as nonpharmacological adjuvant interventions such as biophysical stimulation and psychotherapy. In summary, treatment recommendations for TRD in the elderly favor a multimodal approach, combining pharmacological and nonpharmacological treatments.

Treatment patterns and healthcare utilization of patients with treatment-resistant depression estimated using health insurance database: A population-based study from Taiwan

BACKGROUND

Determining the proportion of patients with treatment-resistant depression (TRD) among patients with unipolar depression receiving adequate pharmacological treatment (pharmaceutically treated depression [PTD]) is clinically important and may affect health care utilization. In Taiwan, these issues can be assessed by analyzing population-based data.

METHODS

The present study included data from the Taiwan National Health Insurance Research Database from 2010 to 2017. Among patients with depression, PTD was defined by the receipt of at least one adequate antidepressant treatment, and TRD was defined as receiving a third adequate antidepressant treatment after failure to respond to two prior treatments. Time of progression from PTD to TRD was estimated via the Kaplan-Meier function. A propensity-matched case-comparison cohort approach was used to compare resource utilization between patients with non-TRD PTD and TRD.

RESULTS

TRD was defined in 11.2 % of patients with unipolar depression and 37.1 % of PTD patients. The time of progression from PTD to TRD was approximately 1 year. Most TRD patients were women, middle-aged, and treated in general practice clinics. Antidepressant monotherapy, followed by antidepressant with augmentation, was the most common treatment strategy applied to TRD patients. Medical utilization was significantly higher in patients with TRD than those with non-TRD PTD across most aspects.

LIMITATIONS

TRD was defined based on pharmacological treatment patterns, as the reasons for changes in antidepressant regimens were not available.

CONCLUSION

Approximately one-third of patients with PTD developed TRD, often soon after receiving adequate pharmacological treatment. Patients with TRD used more medical resources than patients with non-TRD PTD.

Combining psychopharmacotherapy and psychotherapy is not associated with better treatment outcome in major depressive disorder - evidence from the European Group for the Study of Resistant Depression

Despite plenty of effective antidepressant (AD) treatments, the outcome of major depressive disorder (MDD) is often unsatisfactory, probably due to improvable exploitation of available therapies. This European, cross-sectional, naturalistic multicenter study investigated the frequency of additional psychotherapy in terms of a manual-driven psychotherapy (MDP) in 1410 adult in- and outpatients with MDD, who were primarily treated with AD psychopharmacotherapy. Socio-demographic and clinical patterns were compared between patients receiving both treatments and those lacking concomitant MDP. In a total of 1279 MDD patients (90.7%) with known status of additional MDP, those undergoing a psychopharmacotherapy-MDP combination (31.2%) were younger, higher educated, more often employed and less severely ill with lower odds for suicidality as compared to patients receiving exclusively psychopharmacotherapy (68.8%). They experienced an earlier mean age of MDD onset, melancholic features, comorbid asthma and migraine and received lower daily doses of their first-line ADs. While agomelatine was more often established in these patients, MDD patients without MDP received selective serotonin reuptake inhibitors more frequently. These two patient groups did not differ in terms of response, non-response and treatment resistant depression (TRD). Accordingly, the employment of additional MDP could not be related to better treatment outcomes in MDD. The fact that MDP was applied in a minority of patients with rather beneficial socio-demographic and clinical characteristics might reflect inferior accessibility of these psychotherapeutic techniques for socially and economically disadvantaged populations.

Relative effectiveness of augmentation treatments for treatment-resistant depression: a systematic review and network meta-analysis

Most interventions for treatment-resistant depression (TRD) are added as augmenters. We aimed to determine the relative effectiveness of augmentation treatments for TRD. This systematic review and network meta-analysis (NMA) sought all randomized trials of pharmacological and psychological augmentation interventions for adults meeting the most common clinical criteria for TRD. The NMA compared the intervention effectiveness of depressive symptoms for TRD augmentation. Of 36 included trials, 27 were suitable for inclusion in NMA, and no psychological trials could be included in the absence of a common comparator. Antipsychotics (13 trials), mood stabilizers (three trials), NMDA-targeting medications (five trials), and other mechanisms (3 trials) were compared against placebo. NMDA treatments were markedly superior to placebo (ES = 0.91, 95% CI 0.67 to 1.16) and head-to-head NMA suggested that NMDA therapies had the highest chance of being an effective treatment option compared to other pharmacological classes. This study provides the most comprehensive evidence of augmenters' effectiveness for TRD, and our GRADE recommendations can be used to guide guidelines to optimize treatment choices. Although conclusions are limited by paucity of, and heterogeneity between, trials as well as inconsistent reports of treatment safety. This work supports the use of NMDA-targeting medications such as ketamine.