Epidemiology of pharmaceutically treated depression and treatment resistant depression in South Korea

Analysis of Antipsychotic Dosage in Patients With Tardive Dyskinesia: A Case-Control Study Using the Claims Database of the Corporate Health Insurance Association

PURPOSE

This study aimed to assess the association between antipsychotic doses and the risk of tardive dyskinesia (TD) in clinical practice using a Japanese claims database from 2010 to 2020.

METHODS

The study population included patients 15 years or older with a diagnosis record of schizophrenia, depression, or bipolar disorder who were prescribed antipsychotics. Using a case-control design, we categorized patients newly diagnosed with TD as cases, with corresponding 1:10 matching in the control group. The primary endpoint was the relative risk of TD in the >median dose and ≤median dose groups, as determined using conditional logistic regression analysis adjusted for age.

RESULTS

The analysis population included 58,452 patients, and the median daily antipsychotic dose was 75 mg/d of chlorpromazine equivalent (CPZE). Of these, 80 were identified as TD cases, and doses >75 mg/d were associated with a significantly increased risk of TD at the last prescription and the maximum dose, respectively, before the date of the first diagnosis of TD. Post-hoc analysis further showed a significant association between doses ≥300 mg/d and the risk of TD compared to doses ≤75 mg/d and doses >75 to <300 mg/d. Comparing ≥300 mg/d versus >75 to <300 mg/d, the odd ratios at the last prescription and maximum dose before the first diagnosis of TD were 3.40 and 3.50, respectively.

CONCLUSIONS

In the Japanese medical claims database of patients receiving relatively low doses of antipsychotics, doses >75 mg/d were associated with an increased risk of TD in a dose-dependent manner.

Study to determine the epidemiology of treatment-resistant depression among the Saudi Arabian population: A cross-sectional study

BACKGROUND

Depression is a common mental health disorder that affects millions of people worldwide. Globally, major depressive disorder (MDD) is a public health concern; nearly, it affects more than 300 million people. The coronavirus disease 2019 (COVID-19) pandemic lockdown, travel restrictions, social distancing, and COVID-19 vaccine acceptance have aggravated psychological disorders, such as depression and suicidal tendencies. Treatment-resistant depression (TRD) is typically defined as a lack of response to at least two different antidepressant medications or psychotherapies. TRD is common and has been associated with higher comorbidities and prolonged duration of illness, leading to a substantial medical and economic burden.

MATERIALS AND METHODS

A cross-sectional study was designed to determine the epidemiology and estimate the prevalence of TRD in Abha City, Assir Region, Kingdom of Saudi Arabia. The study includes adult patients who were attended to the psychiatry department and aged 18-65 years diagnosed with major depressive depression. A total of 651 study participants were recruited.

RESULTS

Of the total 651 depressive disorder cases, 134 (20.6%) were reported as TRD and the remaining 517 (79.4%) were nontreatment-resistant depressive cases. Of the 651 depression participants, 176 (27%) were males and 475 (73%) were females. More than one-quarter (180 (28%)) had been associated with chronic morbidity. One-tenth of the depressive patients were suffering from thyroid disorders, followed by hypertension (10%), autoimmune diseases (10%), and diabetes mellitus (8%).

CONCLUSIONS

TRD emerged as a threat to public health and challenging psychiatric care providers, and further innovative techniques and effective newer drugs to treat depression need to be researched. The treatment complaint mechanism is warranted, encouraging people to get treatment from the psychiatrist by removing the stigma of mental illness, which is needed to improve the quality of life of TRD patients.

The prevalence and economic burden of treatment-resistant depression in Thailand

BACKGROUND

The objectives of this study were to investigate the proportion of treatment-resistant depression (TRD) among patients with diagnosed major depressive disorder (MDD) and undergoing antidepressant treatment, to estimate the economic cost of MDD, TRD, and non-treatment-resistant depression (non-TRD), and to examine the differences between TRD and non-TRD MDD in a Thai public tertiary hospital.

METHODS

This was a combined study between retrospective review of medical records and a cross-sectional survey. The sample size was 500 dyads of antidepressant-treated MDD patients and their unpaid caregivers. MDD patients' medical records, the concept of healthcare resource utilization, the Work Productivity and Activity Impairment Questionnaire: depression and mood & mental state versions (WPAI: D, MM), the Class Impairment Questionnaire (CIQ), and the Family Experiences Interview Schedule (FEIS) were applied as the tools of the study. Pearson Chi's square, Fisher's Exact test, and independent T-test were employed for statistical analysis.

RESULTS

The proportion of TRD was 19.6% among antidepressant-treated MDD patients in a Thai tertiary public hospital. The results of the study indicated that several factors showed a statistically significant association with TRD criteria. These factors included younger age of MDD patients, a younger age of onset of MDD, lower body mass index (BMI), a history of suicide attempts and self-harm, as well as frequent smoking behavior. The annualized economic cost of TRD was 276,059.97 baht per person ($7,668.33), which was significantly higher than that of cost of non-TRD (173,487.04 baht or $4,819.08). The aggregated economic costs of MDD were 96.8 million baht annually ($2.69 M) if calculated from 500 MDD patients and unpaid caregivers. This contributed to the economic cost of TRD 27.05 million baht (98 respondents) and the economic cost of non-TRD 69.74 million baht (402 respondents).

CONCLUSIONS

The economic burden associated with TRD was significantly higher compared to non-TRD among antidepressant-treated MDD patients. Specifically, both direct medical costs and indirect costs were notably elevated in the TRD group.

Association between Depression and Mortality in Patients with Pain Conditions: A South Korean Nationwide Cohort Study

PURPOSE

Patients with pain conditions may experience depression that greatly complicates treatment. In this study, we examined risk factors for depression in patients with pain conditions and associations between depression and long-term mortality in such patients.

MATERIALS AND METHODS

Data from the National Health Insurance Service database in South Korea were used in this cohort study. A total of 2.5% of adult patients diagnosed with pain conditions in 2010 were selected using a stratified random sampling technique and included for analysis. We performed multivariate logistic regression modelling to identify risk factors associated with depression and multivariate Cox regression modelling to determine whether depression is associated with 10-year survival outcomes in patients with pain conditions.

RESULTS

In total, data from 1808043 patients with pain conditions in 2010 were analyzed. Among them, 70148 (3.9%) patients had depression. Multivariate logistic regression modelling identified older age, comorbidities, analgesics, female sex, living in an urban area, and other underlying psychiatric morbidities as potential risk factors for depression in patients with pain conditions. Multivariate Cox regression revealed that 10-year all-cause mortality in patients with depression was 1.13-fold (hazard ratio, 1.13; 95% confidence interval, 1.11-1.16; p<0.001) higher than that in patients without depression and pain conditions.

CONCLUSION

We identified a few potential risk factors for depression among South Korean patients with pain conditions. Depression was associated with elevated 10-year all-cause mortality in patients with pain conditions.

Overview of treatment-resistant depression

Patients with major depressive disorder (MDD) often exhibit an inadequate treatment response or failure to achieve remission following treatment with antidepressant drugs. Treatment-resistant depression (TRD) is proposed to identify this clinical scenario. Compared to those without TRD, patients with TRD have significantly lower health-related quality of life in mental and physical dimensions, more functional impairment and productivity loss, and higher healthcare costs. TRD imposes a massive burden on the individual, family, and society. However, a lack of consensus on the TRD definition limits the comparison and interpretation of TRD treatment efficacy across trials. Furthermore, because of the various TRD definitions, there is scarce treatment guideline specifically for TRD, in contrast to the rich treatment guidelines for MDD. In this chapter, common issues related to TRD, such as proper definitions of an adequate antidepressant trial and TRD, were carefully reviewed. Prevalence of and clinical outcomes related to TRD were summarized. We also summarized the staging models ever proposed for the diagnosis of TRD. Furthermore, we highlighted variations in the definition regarding the lack of or an inadequate response in treatment guidelines for depression. Up-to-date treatment options for TRD, including pharmacological strategies, psychotherapeutic interventions, neurostimulation techniques, glutamatergic compounds, and even experimental agents were reviewed.

Investigation of the pharmacological treatment patterns of Chinese patients with major depressive disorder under real-world settings using multi-channel sequence analysis

Background

Despite many treatment guidelines available now, the treatment patterns of major depressive disorder (MDD) in China haven't been well-understood due to complexity and diversity.

Aim

To describe pharmacological treatment patterns of MDD patients in real-world settings using electronic health records from a major psychiatric hospital in China.

Methods

MDD patients (18-65 years, ICD-10: F32.x, F33.x) newly initiated single antidepressant (AD) in 2015 were enrolled, the date of first AD prescription during the study period was defined as index date, and eligible patients were followed up to 1 year. Treatment patterns were revealed and analyzed using multi-channel sequence analysis (MCSA), considering patients' chronological sequences (in days) of AD prescription, cumulative treatment step(s), and polypharmacy usage during the follow-up.

Results

This study (n = 5,003) identified four types of MDD treatment patterns. The first type (1-time treatment) represents the largest proportion of patients (73.6%, n = 3,686), followed by the second type (6-month consistent treatment) and third type (long-term, consistent treatment) collectively accounted for 20.6% (n = 1,031) of patients, by contrast the last type (long-term, inconsistent treatment) made up the rest 5.7% (n = 286) of patients while exhibiting the most complicated treatments patterns. The choice of AD was dominated by selective serotonin reuptake inhibitors (SSRIs), while treatment duration spent in polypharmacy spanned at 2.8%, 16.4%, 2.0%, and 36.5% over the four types, respectively.

Conclusion

Treatment patterns reflecting real-world pharmacological treatment practices of MDD in China were revealed using MCSA. The observed discrepancies between real-world practice and treatment guidelines provided additional insights in improving the clinical management of MDD.

Associations of unspecified pain, idiopathic pain and COVID-19 in South Korea: a nationwide cohort study

Background

Few studies have investigated unspecified or idiopathic pain associated with COIVD-19. This study aimed to provide the incidence rates of unspecified pain and idiopathic pain in patients with COVID-19 for 90 days after COVID-19 diagnosis.

Methods

A propensity score matched cohort was used, including all patients with COVID-19 in South Korea, and analyzed their electronic medical records. The control group consisted of those who had not had tests for COVID-19 at all. Unspecified pain diagnoses consisted of diagnoses related to pain included in the ICD-10 Chapter XVIII. Idiopathic pain disorders included fibromyalgia, temporomandibular joint disorders, headaches, chronic prostatitis, complex regional pain syndrome, atypical facial pain, irritable bowel syndrome, and interstitial cystitis.

Results

After matching, the number of participants in each group was 7,911. For most unspecified pain, the incidences were higher in the COVID-19 group (11.7%; 95% confidence interval [CI], 11.0–12.5) than in the control group (6.5%; 95% CI, 6.0–7.1). For idiopathic pain, only the headaches had a significantly higher incidence in the COVID-19 group (6.6%; 95% CI, 6.1–7.2) than in the control group (3.7%; 95% CI, 3.3–4.1). However, using a different control group that included only patients who visited a hospital at least once for any reasons, the incidences of most unspecified and idiopathic pain were higher in the control group than in the COVID-19 group.

Conclusions

Patients with COVID-19 might be at a higher risk of experiencing unspecified pain in the acute phase or after recovery compared with individuals who had not had tests for COVID-19.

One-year incidence rate of Treatment Resistant Depression (TRD) and treatment characteristics in China

BACKGROUND

Little is known about the characteristics of Treatment-Resistant Depression (TRD) in China. In previous studies various identification approaches have led to a wide range of results, and it is unclear how Chinese patients compare to those in other studies.

METHODS

This is a retrospective cohort study using electronic health records (EHR) from two major psychiatric hospitals in China. Adult major depressive disorder (MDD) patients who initiated pharmaceutical treatment during 2010-2018 were enrolled and follow-up was 1 year. TRD was primarily identified by consensus definition of two failures of adequate (≥4 weeks) regimens. Alternative regimens of 2-weeks and 6-weeks duration, and a data-driven definition were also applied.

RESULTS

In the two hospitals, 12,257 (mean age: 40.8y, 63.6% female) and 8314 (mean age: 42.4y, 68.4% female) eligible patients were included. The 1-year incidence rate of TRD was estimated to be 5.2%-7.7% using the primary definition. TRD patients had mean treatment duration of 302.5 days and 285.7 days; had 3.6 and 3.7 treatment steps on average; 94.0% and 72.6% were prescribed polypharmacy regimens, which were all marginally greater than that of non-TRD patients. Alternative definitions resulted in a wide range of incidence estimates (0.5%-20.0%).

LIMITATIONS

Medications were assumed to be consumed as prescribed and lack of rating scales from EHRs may limit our TRD identification.

CONCLUSIONS

The incidence of TRD among Chinese MDD patients was comparable to other countries under similar settings and more complex treatment characteristics were observed among TRD patients. Alternative TRD definitions revealed the need for better treatment management in practices.

Long-term Safety and Efficacy of Esketamine Nasal Spray Plus an Oral Antidepressant in Patients with Treatment-resistant Depression- an Asian Sub-group Analysis from the SUSTAIN-2 Study

Objective

To evaluate the long-term safety and efficacy of intranasal esketamine in patients with treatment-resistant depression from the Asian subgroup of the SUSTAIN-2 study.

Methods

SUSTAIN-2 was a phase 3, open-label, single-arm, multicenter study comprising a 4-week screening, 4-week induction, 48-week optimization/maintenance, and 4-week follow-up (upon esketamine discontinuation) phase. Patients with treatment-resistant depression received esketamine plus an oral antidepressant during the treatment period.

Results

The incidence of ≥ 1 serious treatment-emergent adverse event (TEAE) among the 78 subjects from the Asian subgroup (Taiwan 33, Korea 26, Malaysia 19) was 11.5% (n = 9); with no fatal TEAE. 13 Asian patients (16.7%) discontinued esketamine due to TEAEs. The most common TEAEs were dizziness (37.2%), nausea (29.5%), dissociation (28.2%), and headache (21.8%). Most TEAEs were mild to moderate in severity, transient and resolved on the same day. Upon discontinuation of esketamine, no trend in withdrawal symptoms was observed to associate long-term use of esketamine with withdrawal syndrome. There were no reports of drug seeking, abuse, or overdose. Improvements in symptoms, functioning and quality of life, occurred during in the induction phase and were generally maintained through the optimization/maintenance phases of the study.

Conclusion

The safety and efficacy of esketamine in the Asian subgroup was generally consistent with the total SUSTAIN-2 population. There was no new safety signal and no indication of a high potential for abuse with the long-term (up to one year) use of esketamine in the Asian subgroup. Most of the benefits of esketamine occurred early during the induction phase.

Association Between Dementia Development and COVID-19 among Individuals Who Tested Negative for COVID-19 in South Korea: A Nationwide Cohort Study

We aim to assess whether the number of newly diagnosed dementia increases and whether comorbid psychiatric symptoms of patients with dementia worsen, in people who were tested for COVID-19. We used electronic medical records from a nationwide cohort consisting of people who tested positive (positive group), tested negative (negative group), and those who did not receive the test (control group) for COVID-19. For people with neither a history of dementia nor mild cognitive disorder (MCI), the negative group was more likely to develop dementia than the control group, and less likely to develop MCI than the positive group. For people who already had dementia, the negative group was more likely to develop comorbid psychiatric disorders than the control group, but less likely than the positive group. These findings suggest the necessity of managing mental health not only for patients with COVID-19 but also for people who tested negative for COVID-19.

Clinical characteristics of treatment-resistant depression in adults in Hungary: Real-world evidence from a 7-year-long retrospective data analysis

Purpose

Treatment-resistant depression (TRD) is associated with a poor quality of life and high economic burden. This observational retrospective epidemiological study aimed to estimate the proportion of patients with TRD within a cohort of patients with major depressive disorder (MDD) in Hungary and examine the mortality and comorbidities of patients with and without TRD.

Patients and methods

This study included patients with MDD who experienced onset of a new depressive episode between 01 January 2009 and 31 August 2015, using data from a nationwide, longitudinal database.

Results

Overall, 99,531 patients were included in the MDD cohort, of which 8,268 (8.3%) also met the criteria for TRD. The overall survival of non-TRD patients was longer than in TRD patients; the risk of mortality for TRD patients was significantly higher than of non-TRD patients (HR [CI] 1.381 [1.212–1.571]; p<0.001). Patients with TRD had a significantly higher probability of having “Neurotic, stress-related and somatoform disordersˮ, autoimmune conditions, cardio- or cerebrovascular diseases, thyroid gland diseases and self-harming behaviour not resulting in death than non-TRD patients (for all comparisons, p values were less than 0.005).

Discussion

To our best knowledge, this is the first study to assess the frequency of TRD in Hungary. In a cohort of Hungarian MDD patients, we have found that the proportion of TRD (~8.3%) is comparable to those reported in previous studies with similar methodology from other countries. The majority of our other main findings (e.g. more frequent self-harming behaviour, increased risk of “Neurotic, stress-related and somatoform disordersˮ and higher overall mortality in TRD subjects) are also in line with previous results from other countries. Taking the substantial proportion of patients with TRD into consideration, a more comprehensive and targeted treatment strategy would be required for these individuals.

Real-world data analysis of the clinical and economic burden and risk factors in patients with major depressive disorder with an inadequate response to initial antidepressants

AIM

We aimed to determine the incidence of and identify the factors associated with treatment-resistant depression (TRD), psychiatric conditions, hospitalization, and cost in patients with major depressive disorder (MDD) who were treated using second-line strategies after an inadequate response to initial antidepressants (AD).

MATERIALS AND METHODS

Using South Korean National Health Insurance claims data (1 January 2013 to 30 June 2018), we conducted a retrospective cohort analysis in newly treated patients with MDD who subsequently switched or added AD, or added atypical antipsychotics (AAPs) as a second-line treatment. We assessed the incidence of treatment-resistant depression (TRD), psychiatric conditions, and hospitalization for the first 2 years and costs in the third year. Odds ratios (ORs) or relative ratios were estimated using logistic and linear regression models to identify the risk factors for clinical and economic outcomes.

RESULTS

In 15,887 patients, the TRD was 16.81% during the 24-month follow-up period (14.14% in switching AD, 19.65% in adding AD, and 19.91% in adding AAP; p < 0.0001). When adding AD or AAP, the OR of TRD was 1.43 (95% confidence interval (CI): 1.30-1.56) and 1.42 (95% CI: 1.23-1.65), respectively, compared to switching AD. However, these factors were not associated with the incidence of psychiatric conditions. Adding AAP increased hospitalization (OR = 1.25, 95% CI: 1.11-1.41), the number of inpatient days by 2.57-fold (95% CI: 1.75-3.76), and cost by 1.20-fold (95% CI: 1.02-1.40), compared to switching AD; adding AD did not show a significant association with these outcomes.

CONCLUSIONS

In patients with MDD with inadequate responses to initial AD, TRD still occurred after subsequent treatments according to clinical guidelines. Since the effectiveness of second treatment strategies can differ in reality, further analysis of the clinical and economic evidence regarding second treatment strategies, such as adding AD or AAP, is needed using real-world data.

Antidepressant Use and the Risk of Major Adverse Cardiovascular Events in Patients Without Known Cardiovascular Disease: A Retrospective Cohort Study

Aims: Conflicting data exist on whether an association exists between antidepressants and the risk of major adverse cardiovascular events (MACEs) in patients with depression. This may be due to the use of various study designs and residual or unmeasured confounding. We aimed to assess the association between antidepressant use and the risk of MACEs while considering various covariates, including severity of depression and the cardiovascular disease (CVD) risk score.

Methods: Patients newly diagnosed with depression with no history of ischemic heart disease and stroke were followed-up from 2009 to 2015. We conducted Cox proportional hazard regression analysis to estimate hazard ratios (HRs) for each antidepressant for MACE risk.

Result: We followed-up (median, 4.4 years) 31,830 matched patients with depression (15,915 antidepressant users and 15,915 non-users). In most patients (98.7%), low-dose tricyclic antidepressants (TCAs) were related with a significantly increased risk of MACEs [adjusted HR = 1.20, 95% confidence interval (CI) = 1.03–1.40]. Duration response relationship showed a gradually increasing HR from 1.15 (95% CI = 0.98–1.33; <30 days of use) to 1.84 (95% CI = 1.35–2.51; ≥365 days of use) (p for trend <0.01). High Korean atherosclerotic CVD risk score (≥7.5%) or unfavorable lifestyle factors (smoking, alcohol intake, and exercise) were significantly associated with MACEs.

Conclusion: Even at low doses, TCA use was associated with MACEs during primary prevention. Longer duration of TCA use correlated with higher HR. Careful monitoring is needed with TCA use in patients with no known CVD history.

Cost analysis of depression using the national insurance system in South Korea: a comparison of depression and treatment-resistant depression

Background

The incidence and burden of depressive disorders are increasing in South Korea. There are many differences between pharmaceutically treated depression (PTD) and treatment-resistant depression (TRD), including the economic consequences; however, to our knowledge, the economic burden of depression is understudied in South Korea. Therefore, the objective of the present study was to calculate the different economic costs of PTD and TRD in South Korea, specifically by comparing several aspects of medical care.

Methods

This study comprised patients aged 18 and over who were newly prescribed antidepressants for more than 28 days with a depression code included from January 1, 2012, to December 31, 2012, by the Health Insurance Review and Assessment Service (HIRA). TRD was classified as more than two antidepressant regimen failures in PTD patients. The cost was calculated based on the cost reflected on the receipt registered with HIRA.

Results

Of the 834,694 patients with PTD, 34,812 patients (4.17%) were converted to TRD. The cost of medical care for TRD (6,610,487 KRW, 5881 USD) was approximately 5 times higher than the cost of non-TRD (1,273,045 KRW, 1133 USD) and was significantly higher for patients with or without depression and suicide codes. Medical expenses incurred by non-psychiatrists were roughly 1.7 times higher than those incurred by psychiatrists.

Conclusions

TRD patients had significantly higher healthcare costs than PTD patients. Identifying these financial aspects of care for depression can help to establish a more effective policy to reduce the burden on mentally ill patients.

Definition and Identification of Patients with Treatment-Resistant Depression in Real-World Clinical Practice Settings Across Asia

PURPOSE

An Asia-Pacific expert consensus defined treatment-resistant depression (TRD) as failure of ≥2 antidepressants given at adequate doses for 6-8 weeks during a major depressive episode. A survey examined how TRD was being diagnosed in real-world practices across Asia. An expert panel then interpreted the results and provided practical recommendations.

METHODS

Between March and July 2018, 246 clinicians from Hong Kong, Japan, Mainland China, South Korea, and Taiwan were surveyed on how they identified TRD patients according to their own definitions.

RESULTS

Most physicians described antidepressant failure as "no response" (79%) or "inadequate response" (82%); fewer chose "failure to achieve remission" (45%). About 40% did not routinely use clinical tools to assess response. Around 52% defined adequate dose target as achieving the label's upper dose limit. About 58% would treat for 4-8 weeks before determining antidepressant failure. Most (76%) required the ≥2 qualifying antidepressant failures to be from different classes. Approximately 60% considered antidepressant failure(s) from previous depressive episode(s) when diagnosing TRD.

CONCLUSION

Considering the survey results, antidepressant failure can be defined as a failure to achieve remission, or more practically as <50% improvement in depressive symptoms or inability to return to work/study, and confirmed with a clinical tool. TRD diagnosis also requires ≥2 qualifying antidepressant failures within the same depressive episode; from the same or different classes; and achieving at least the minimum effective antidepressant dose for 6-8 weeks.

Management of Treatment-Resistant Depression in Real-World Clinical Practice Settings Across Asia

PURPOSE

Consensus is lacking on the management of treatment-resistant depression (TRD), resulting in significant variations on how TRD patients are being managed in real-world practice. A survey explored how clinicians managed TRD across Asia, followed by an expert panel that interpreted the survey results and provided recommendations on how TRD could be managed in real-world clinical settings.

METHODS

Between March and July 2018, 246 clinicians from Hong Kong, Japan, Mainland China, South Korea, and Taiwan completed a survey related to their treatment approaches for TRD.

RESULTS

The survey showed physicians using more polytherapy (71%) compared to maintaining patients on monotherapy (29%). The most commonly (23%) administered polytherapy involved antidepressant augmentation with antipsychotics that 19% of physicians also indicated as their most important approach for managing TRD. The highest number of physicians (34%) ranked switching to another class of antidepressants as their most important approach, while 16% and 9% chose antidepressant combinations and electroconvulsive therapy (ECT), respectively.

CONCLUSION

Taking into account the survey results, the expert panel made general recommendations on the management of TRD. TRD partial-responders to antidepressants should be considered for augmentation with second-generation antipsychotics. For non-responders, switching to another class of antidepressants ought to be considered. TRD patients achieving remission with acute treatment should consider continuing their antidepressants for at least another 6 months to prevent relapse. ECT is a treatment consideration for patients with severe depression or persistent symptoms despite multiple adequate trials of antidepressants. Physicians should also consider the response, tolerability and adherence to the current and previous antidepressants, the severity of symptoms, comorbidities, concomitant medications, preferences, and cost when choosing a TRD treatment approach for each individual patient.