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McIntyre RS, Alsuwaidan M, Baune BT, Berk M, Demyttenaere K, Goldberg JF, Gorwood P, Ho R, Kasper S, Kennedy SH, Ly-Uson J, Mansur RB, McAllister-Williams RH, Murrough JW, Nemeroff CB, Nierenberg AA, Rosenblat JD, Sanacora G, Schatzberg AF, Shelton R, Stahl SM, Trivedi MH, Vieta E, Vinberg M, Williams N, Young AH, Maj M. Treatment-resistant depression: definition, prevalence, detection, management, and investigational interventions. World Psychiatry 2023; 22:394-412. [PMID: 37713549 PMCID: PMC10503923 DOI: 10.1002/wps.21120] [Citation(s) in RCA: 86] [Impact Index Per Article: 86.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/17/2023] Open
Abstract
Treatment-resistant depression (TRD) is common and associated with multiple serious public health implications. A consensus definition of TRD with demonstrated predictive utility in terms of clinical decision-making and health outcomes does not currently exist. Instead, a plethora of definitions have been proposed, which vary significantly in their conceptual framework. The absence of a consensus definition hampers precise estimates of the prevalence of TRD, and also belies efforts to identify risk factors, prevention opportunities, and effective interventions. In addition, it results in heterogeneity in clinical practice decision-making, adversely affecting quality of care. The US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have adopted the most used definition of TRD (i.e., inadequate response to a minimum of two antidepressants despite adequacy of the treatment trial and adherence to treatment). It is currently estimated that at least 30% of persons with depression meet this definition. A significant percentage of persons with TRD are actually pseudo-resistant (e.g., due to inadequacy of treatment trials or non-adherence to treatment). Although multiple sociodemographic, clinical, treatment and contextual factors are known to negatively moderate response in persons with depression, very few factors are regarded as predictive of non-response across multiple modalities of treatment. Intravenous ketamine and intranasal esketamine (co-administered with an antidepressant) are established as efficacious in the management of TRD. Some second-generation antipsychotics (e.g., aripiprazole, brexpiprazole, cariprazine, quetiapine XR) are proven effective as adjunctive treatments to antidepressants in partial responders, but only the olanzapine-fluoxetine combination has been studied in FDA-defined TRD. Repetitive transcranial magnetic stimulation (TMS) is established as effective and FDA-approved for individuals with TRD, with accelerated theta-burst TMS also recently showing efficacy. Electroconvulsive therapy is regarded as an effective acute and maintenance intervention in TRD, with preliminary evidence suggesting non-inferiority to acute intravenous ketamine. Evidence for extending antidepressant trial, medication switching and combining antidepressants is mixed. Manual-based psychotherapies are not established as efficacious on their own in TRD, but offer significant symptomatic relief when added to conventional antidepressants. Digital therapeutics are under study and represent a potential future clinical vista in this population.
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Affiliation(s)
- Roger S McIntyre
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Mohammad Alsuwaidan
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Bernhard T Baune
- Department of Psychiatry, University of Münster, Münster, Germany
- Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia
| | - Michael Berk
- Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia
- Deakin University IMPACT Institute, Geelong, VIC, Australia
| | - Koen Demyttenaere
- Department of Psychiatry, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Joseph F Goldberg
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Philip Gorwood
- Department of Psychiatry, Sainte-Anne Hospital, Paris, France
| | - Roger Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Institute for Health Innovation and Technology, National University of Singapore, Singapore
| | - Siegfried Kasper
- Department of Psychiatry and Psychotherapy and Center of Brain Research, Molecular Neuroscience Branch, Medical University of Vienna, Vienna, Austria
| | - Sidney H Kennedy
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Josefina Ly-Uson
- Department of Psychiatry and Behavioral Medicine, University of The Philippines College of Medicine, Manila, The Philippines
| | - Rodrigo B Mansur
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - R Hamish McAllister-Williams
- Northern Center for Mood Disorders, Translational and Clinical Research Institute, Newcastle University, and Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - James W Murrough
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Andrew A Nierenberg
- Dauten Family Center for Bipolar Treatment Innovation, Massachusetts General Hospital, Boston, MA, USA
| | - Joshua D Rosenblat
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Gerard Sanacora
- Department of Psychiatry, Yale University, New Haven, CT, USA
| | - Alan F Schatzberg
- Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, USA
| | - Richard Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stephen M Stahl
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Madhukar H Trivedi
- Department of Psychiatry, University of Illinois Chicago, Chicago, IL, USA
| | - Eduard Vieta
- Department of Psychiatry and Psychology, Institute of Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
| | - Maj Vinberg
- Mental Health Centre, Northern Zealand, Copenhagen University Hospital - Mental Health Services CPH, Copenhagen, Denmark
| | - Nolan Williams
- Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, USA
| | - Allan H Young
- Department of Psychological Medicine, King's College London, London, UK
| | - Mario Maj
- Department of Psychiatry, University of Campania "Luigi Vanvitelli", Naples, Italy
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Wang X, Fan X, Zhang L, Liu X, Ji Z. Repetitive transcranial magnetic stimulation in the treatment of middle-aged and elderly major depressive disorder: A randomized controlled trial. Medicine (Baltimore) 2023; 102:e34841. [PMID: 37657019 PMCID: PMC10476736 DOI: 10.1097/md.0000000000034841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/28/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND Studies have reported the use of repetitive transcranial magnetic stimulation (rTMS) in patients with major depressive disorder (MDD). However, most studies focus on antidepressant effect of rTMS, but few on cognitive aspects. The present study aimed to explore the effect of rTMS on BDNF levels and cognitive function in the treatment of middle-aged and elderly MDD. METHODS This was a randomized controlled trial. A total of 120 elderly patients with MDD treated in The Second Affiliated Hospital of Xi'an Medical University from January 2021 to January 2023 were selected as research subjects. The patients were randomly divided into control group (n = 60, patients received simple oral treatment with escitalopram and sham rTMS) and study group (n = 60, patients received oral treatment with escitalopram combined with rTMS) according to the random number table method. We compared the clinical efficacy, serum BDNF levels, and cognitive function between the 2 groups. RESULTS After treatment, the HAMD-17 score in the study group was lower than that in the control group [13.00 (12.00-16.00) vs 17.00 (15.00-19.00), P < .05], and the RBANS score was higher than that in the control group [166.00 (161.25-171.75) vs 133.00 (130.00-136.75), P < .05]. The total effective rate of the research group was 95.0%, which was higher than the 82.0% of the control group (P < .05). The serum BDNF levels [36.00 (33.00-38.00) vs 30.00 (28.00-32.00), P < .05] and MoCA scores [24.00 (22.00-26.75) vs 23.00 (21.00-25.00), P < .05] of the study group were higher than those of the control group. There were no significant adverse reactions during the treatment of both groups. CONCLUSIONS Compared with oral escitalopram alone, repeated transcranial magnetic stimulation in the treatment of middle-aged and elderly patients with major depressive disorder can further improve the efficacy, and can more effectively improve the BDNF level and cognitive function, with ideal safety.
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Affiliation(s)
- Xiaofang Wang
- Department of Neurology, The Second Affiliated Hospital of Xi’an Medical University, Xi’an, China
| | - Xiubo Fan
- Department of Neurology, The Second Affiliated Hospital of Xi’an Medical University, Xi’an, China
| | - Lihui Zhang
- Department of Neurology, The Second Affiliated Hospital of Xi’an Medical University, Xi’an, China
| | - Xin Liu
- Department of Neurology, The Second Affiliated Hospital of Xi’an Medical University, Xi’an, China
| | - Zhi Ji
- Department of Neurology, The Second Affiliated Hospital of Xi’an Medical University, Xi’an, China
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Malhi GS, Bell E, Bassett D, Boyce P, Bryant R, Hopwood M, Lyndon B, Mulder R, Porter R, Singh AB, Murray G. The management of depression: the evidence speaks for itself. Br J Psychiatry 2023; 222:97-99. [PMID: 36082788 DOI: 10.1192/bjp.2022.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Comparing the recommendations of two recently published national clinical practice guidelines for depression, this editorial highlights the concordance of advice concerning the selection and sequencing of therapies. Lifestyle and psychological interventions feature prominently and there is broad agreement regarding medication choice and optimisation strategies. The guidelines are therefore a useful resource.
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Affiliation(s)
- Gin S Malhi
- Academic Department of Psychiatry, Kolling Institute, Northern Clinical School, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia; and CADE Clinic & Mood-T Service, Royal North Shore Hospital, Northern Sydney Local Health District, New South Wales, Australia; and Department of Psychiatry, University of Oxford, UK
| | - Erica Bell
- Academic Department of Psychiatry, Kolling Institute, Northern Clinical School, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia; and CADE Clinic & Mood-T Service, Royal North Shore Hospital, Northern Sydney Local Health District, New South Wales, Australia
| | - Darryl Bassett
- The Hollywood Clinic, Nedlands, Western Australia, Australia
| | - Philip Boyce
- Specialty of Psychiatry, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Richard Bryant
- School of Psychology, University of New South Wales, Sydney, New South Wales, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne, Victoria, Australia; and Professorial Psychiatry Unit, Albert Road Clinic, Melbourne, Victoria, Australia
| | - Bill Lyndon
- Specialty of Psychiatry, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Roger Mulder
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Richard Porter
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Ajeet B Singh
- The Geelong Clinic, St Albans Park, Victoria, Australia; and Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Greg Murray
- Centre for Mental Health, Department of Psychological Sciences, Swinburne University of Technology, Hawthorn, Victoria, Australia
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Gabriel FC, Stein AT, Melo DDO, Fontes-Mota GCH, dos Santos IB, Rodrigues CDS, Dourado A, Rodrigues MC, Fráguas R, Florez ID, Correia DT, Ribeiro E. Guidelines' recommendations for the treatment-resistant depression: A systematic review of their quality. PLoS One 2023; 18:e0281501. [PMID: 36745622 PMCID: PMC9901785 DOI: 10.1371/journal.pone.0281501] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 01/24/2023] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Depression is a serious and widespread mental health disorder. A significant proportion of patients with depression fail to remit after two antidepressant treatment trials, a condition named treatment-resistant depression (TRD). Clinical practice guidelines (CPGs) are instruments aimed to improve diagnosis and treatment. This study objective is to systematically appraise the quality and elaborate a comparison of high-quality CPGs with high-quality recommendations aimed at TRD. METHODS AND ANALYSIS We searched several specialized databases and organizations that develop CPGs. Independent researchers assessed the quality of the CPGs and their recommendations using AGREE II and AGREE-REX instruments, respectively. We selected only high-quality CPGs that included definition and recommendations for TRD. We investigated their divergencies and convergencies as well as weak and strong points. RESULTS Among seven high-quality CPGs with high-quality recommendations only two (Germany's Nationale Versorgungs Leitlinie-NVL and US Department of Veterans Affairs and Department of Defense-VA/DoD) included specific TRD definition and were selected. We found no convergent therapeutic strategy among these two CPGs. Electroconvulsive therapy is recommended by the NVL but not by the VA/DoD, while repetitive transcranial magnetic stimulation is recommended by the VA/DoD but not by the NVL. While the NVL recommends the use of lithium, and a non-routine use of thyroid or other hormones, psychostimulants, and dopaminergic agents the VA/DoD does not even include these drugs among augmentation strategies. Instead, the VA/DoD recommends ketamine or esketamine as augmentation strategies, while the NVL does not mention these drugs. Other differences between these CPGs include antidepressant combination, psychotherapy as a therapeutic augmentation, and evaluation of the need for hospitalization all of which are only recommended by the NVL. CONCLUSIONS High-quality CPGs for the treatment of depression diverge regarding the definition and use of the term TRD. There is also no convergent approach to TRD from currently high-quality CPGs.
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Affiliation(s)
- Franciele Cordeiro Gabriel
- Departamento de Farmácia, Faculdade de Ciências Farmacêuticas, Universidade de São Paulo, São Paulo, São Paulo, Brasil
- * E-mail:
| | - Airton Tetelbom Stein
- Departamento de Saúde Coletiva, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brasil
- Gerência de Ensino e Pesquisa do Grupo Hospitalar Conceição, Porto Alegre, Rio Grande do Sul, Brasil
| | - Daniela de Oliveira Melo
- Departamento de Ciências Farmacêuticas, Instituto de Ciências Ambientais, Químicas e Farmacêuticas, Universidade Federal de São Paulo, Diadema, São Paulo, Brasil
| | | | - Itamires Benício dos Santos
- Departamento de Ciências Farmacêuticas, Instituto de Ciências Ambientais, Químicas e Farmacêuticas, Universidade Federal de São Paulo, Diadema, São Paulo, Brasil
| | - Camila da Silva Rodrigues
- Departamento de Ciências Farmacêuticas, Instituto de Ciências Ambientais, Químicas e Farmacêuticas, Universidade Federal de São Paulo, Diadema, São Paulo, Brasil
| | - Andrea Dourado
- Departamento de Ciências Farmacêuticas, Instituto de Ciências Ambientais, Químicas e Farmacêuticas, Universidade Federal de São Paulo, Diadema, São Paulo, Brasil
| | | | - Renério Fráguas
- Departamento e Instituto de Psiquiatria, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Divisão de Psiquiatria e Psicologia Hospital, São Paulo, Brasil
| | - Ivan D. Florez
- School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics, University of Antioquia, Medellín, Colombia
- Pediatric Intensive Care Unit, Clinica Las Americas-AUNA, Medellin, Colombia
| | - Diogo Telles Correia
- Departamento de Psiquiatria e Psicologia da Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Eliane Ribeiro
- Departamento de Farmácia, Faculdade de Ciências Farmacêuticas, Universidade de São Paulo, São Paulo, São Paulo, Brasil
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