Psilocybin therapy for treatment resistant depression: prediction of clinical outcome by natural language processing

RATIONALE

Therapeutic administration of psychedelics has shown significant potential in historical accounts and recent clinical trials in the treatment of depression and other mood disorders. A recent randomized double-blind phase-IIb study demonstrated the safety and efficacy of COMP360, COMPASS Pathways' proprietary synthetic formulation of psilocybin, in participants with treatment-resistant depression.

OBJECTIVE

While the phase-IIb results are promising, the treatment works for a portion of the population and early prediction of outcome is a key objective as it would allow early identification of those likely to require alternative treatment.

METHODS

Transcripts were made from audio recordings of the psychological support session between participant and therapist 1 day post COMP360 administration. A zero-shot machine learning classifier based on the BART large language model was used to compute two-dimensional sentiment (valence and arousal) for the participant and therapist from the transcript. These scores, combined with the Emotional Breakthrough Index (EBI) and treatment arm were used to predict treatment outcome as measured by MADRS scores. (Code and data are available at https://github.com/compasspathways/Sentiment2D .) RESULTS: Two multinomial logistic regression models were fit to predict responder status at week 3 and through week 12. Cross-validation of these models resulted in 85% and 88% accuracy and AUC values of 88% and 85%.

CONCLUSIONS

A machine learning algorithm using NLP and EBI accurately predicts long-term patient response, allowing rapid prognostication of personalized response to psilocybin treatment and insight into therapeutic model optimization. Further research is required to understand if language data from earlier stages in the therapeutic process hold similar predictive power.

Clinical research challenges posed by difficult-to-treat depression

Approximately one-third of individuals in a major depressive episode will not achieve sustained remission despite multiple, well-delivered treatments. These patients experience prolonged suffering and disproportionately utilize mental and general health care resources. The recently proposed clinical heuristic of 'difficult-to-treat depression' (DTD) aims to broaden our understanding and focus attention on the identification, clinical management, treatment selection, and outcomes of such individuals. Clinical trial methodologies developed to detect short-term therapeutic effects in treatment-responsive populations may not be appropriate in DTD. This report reviews three essential challenges for clinical intervention research in DTD: (1) how to define and subtype this heterogeneous group of patients; (2) how, when, and by what methods to select, acquire, compile, and interpret clinically meaningful outcome metrics; and (3) how to choose among alternative clinical trial design options to promote causal inference and generalizability. The boundaries of DTD are uncertain, and an evidence-based taxonomy and reliable assessment tools are preconditions for clinical research and subtyping. Traditional outcome metrics in treatment-responsive depression may not apply to DTD, as they largely reflect the only short-term symptomatic change and do not incorporate durability of benefit, side effect burden, or sustained impact on quality of life or daily function. The trial methodology will also require modification as trials will likely be of longer duration to examine the sustained impact, raising complex issues regarding control group selection, blinding and its integrity, and concomitant treatments.

Investigating differences in treatment effect estimates between propensity score matching and weighting: a demonstration using STAR*D trial data

PURPOSE

The choice of propensity score (PS) implementation influences treatment effect estimates not only because different methods estimate different quantities, but also because different estimators respond in different ways to phenomena such as treatment effect heterogeneity and limited availability of potential matches. Using effectiveness data, we describe lessons learned from sensitivity analyses with matched and weighted estimates.

METHODS

With subsample data (N = 1292) from Sequenced Treatment Alternatives to Relieve Depression, a 2001-2004 effectiveness trial of depression treatments, we implemented PS matching and weighting to estimate the treatment effect in the treated and conducted multiple sensitivity analyses.

RESULTS

Matching and weighting both balanced covariates but yielded different samples and treatment effect estimates (matched RR 1.00, 95% CI: 0.75-1.34; weighted RR 1.28, 95% CI: 0.97-1.69). In sensitivity analyses, as increasing numbers of observations at both ends of the PS distribution were excluded from the weighted analysis, weighted estimates approached the matched estimate (weighted RR 1.04, 95% CI 0.77-1.39 after excluding all observations below the 5th percentile of the treated and above the 95th percentile of the untreated). Treatment appeared to have benefits only in the highest and lowest PS strata.

CONCLUSIONS

Matched and weighted estimates differed due to incomplete matching, sensitivity of weighted estimates to extreme observations, and possibly treatment effect heterogeneity. PS analysis requires identifying the population and treatment effect of interest, selecting an appropriate implementation method, and conducting and reporting sensitivity analyses. Weighted estimation especially should include sensitivity analyses relating to influential observations, such as those treated contrary to prediction.

Effects of medical and psychological treatment of depression in patients with COPD--a review

Chronic Obstructive Pulmonary Disease (COPD) is a chronic inflammatory lung disease characterized by progressive and only partially reversible symptoms and by considerable negative consequences such as reductions in functional status and quality of life. Comorbid depression is highly prevalent in patients with COPD and related to a worse course of the disease. Despite its negative impact, depression often remains unrecognized and untreated in COPD patients. This review summarizes the current state of findings from studies examining the effects of antidepressant treatments in patients with COPD. Reviewed treatment options are antidepressant medical therapy and cognitive-behavioral therapy (CBT). Antidepressant medical trials include treatments with selective serotonin reuptake inhibitors (SSRI) or tricyclic antidepressants (TCA); CBT was applied using various components. Across both treatment types, the majority of studies included patients with a wide range of psychiatric conditions and especially comorbid symptoms of anxiety were often not controlled. Furthermore, greatly varying instruments and methods for assessing depressive symptoms, small sample sizes and rather heterogeneous results were observed. This makes the comparison of treatment options rather difficult and prevents definite conclusions. However, some important implications valuable for further research were obtained. Some limited data suggested that SSRI might show fewer side effects than TCA. A few antidepressants as well as beneficial effects in other outcomes were observed after antidepressant medical treatment. More clearly, CBT showed some potential in terms of improvements in depressive symptoms, and also in other outcome measures. Patient compliance seems more promising for CBT than for antidepressant medical treatment. Overall, the reviewed studies suggest some promising effects for both treatment types and effect sizes in studies with significant antidepressant effects were reasonable. However, future randomized controlled trials comparing antidepressant medical and cognitive-behavioral therapy will be essential to assess distinct and most favorable treatment effects. Because recent data is often limited, sound diagnostic criteria of depression and adequate sample sizes are necessary to draw firm conclusions on the effects of these antidepressant treatment options in patients with COPD and comorbid depression.

Psychosocial functioning in patients with Treatment-Resistant Depression after group cognitive behavioral therapy

BACKGROUND

Although patients with Treatment Resistant Depression (TRD) often have impaired social functioning, few studies have investigated the effectiveness of psychosocial treatment for these patients. We examined whether adding group cognitive behavioral therapy (group-CBT) to medication would improve both the depressive symptoms and the social functioning of patient with mild TRD, and whether any improvements would be maintained over one year.

METHODS

Forty-three patients with TRD were treated with 12 weekly sessions of group-CBT. Patients were assessed with the Global Assessment of Functioning scale (GAF), the 36-item Short-Form Health Survey (SF-36), the Hamilton Rating Scale for Depression (HRSD), the Dysfunctional Attitudes Scale (DAS), and the Automatic Thought Questionnaire-Revised (ATQ-R) at baseline, at the termination of treatment, and at the 12-month follow-up.

RESULTS

Thirty-eight patients completed treatment; five dropped out. For the patients who completed treatment, post-treatment scores on the GAF and SF-36 were significantly higher than baseline scores. Scores on the HRSD, DAS, and ATQ-R were significantly lower after the treatment. Thus patients improved on all measurements of psychosocial functioning and mood symptoms. Twenty patients participated in the 12-month follow-up. Their improvements for psychosocial functioning, depressive symptoms, and dysfunctional cognitions were sustained at 12 months following the completion of group-CBT.

CONCLUSIONS

These findings suggest a positive effect that the addition of cognitive behavioural group therapy to medication on depressive symptoms and social functioning of mildly depressed patients, showing treatment resistance.

Therapeutic options for treatment-resistant depression

Treatment-resistant depression (TRD) presents major challenges for both patients and clinicians. There is no universally accepted definition of TRD, but results from the US National Institute of Mental Health's (NIMH) STAR*D (Sequenced Treatment Alternatives to Relieve Depression) programme indicate that after the failure of two treatment trials, the chances of remission decrease significantly. Several pharmacological and nonpharmacological treatments for TRD may be considered when optimized (adequate dose and duration) therapy has not produced a successful outcome and a patient is classified as resistant to treatment. Nonpharmacological strategies include psychotherapy (often in conjunction with pharmacotherapy), electroconvulsive therapy and vagus nerve stimulation. The US FDA recently approved vagus nerve stimulation as adjunctive therapy (after four prior treatment failures); however, its benefits are seen only after prolonged (up to 1 year) use. Other nonpharmacological options, such as repetitive transcranial stimulation, deep brain stimulation or psychosurgery, remain experimental and are not widely available. Pharmacological treatments of TRD can be grouped in two main categories: 'switching' or 'combining'. In the first, treatment is switched within and between classes of compounds. The benefits of switching include avoidance of polypharmacy, a narrower range of treatment-emergent adverse events and lower costs. An inherent disadvantage of any switching strategy is that partial treatment responses resulting from the initial treatment might be lost by its discontinuation in favour of another medication trial. Monotherapy switches have also been shown to have limited effectiveness in achieving remission. The advantage of combination strategies is the potential to build upon achieved improvements; they are generally recommended if partial response was achieved with the current treatment trial. Various non-antidepressant augmenting agents, such as lithium and thyroid hormones, are well studied, although not commonly used. There is also evidence of efficacy and increasing use of atypical antipsychotics in combination with antidepressants, for example, olanzapine in combination with fluoxetine (OFC) or augmentation with aripiprazole. The disadvantages of a combination strategy include multiple medications, a broader range of treatment-emergent adverse events and higher costs. Several experimental pharmaceutical treatment alternatives for TRD are also being explored in combination with antidepressants or as monotherapy. These less studied alternative compounds include pindolol, inositol, CNS stimulants, hormones, herbal supplements, omega-3 fatty acids, S-adenosyl-L-methionine, folic acid, lamotrigine, modafinil, riluzole and topiramate. In summary, despite an increasing variety of choices for the treatment of TRD, this condition remains universally undefined and represents an area of unmet medical need. There are few known approved pharmacological agents for TRD (aripiprazole and OFC) and overall outcomes remain poor. This might be an indication that depression itself is a heterogeneous condition with a great diversity of pathologies, highlighting the need for careful evaluation of individuals with depressive symptoms who are unresponsive to treatment. Clearly, more research is needed to provide clinicians with better guidance in making those treatment decisions--especially in light of accumulating evidence that the longer patients are unsuccessfully treated, the worse their long-term prognosis tends to be.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders in Primary Care

These practical guidelines for the biological treatment of unipolar depressive disorders in primary care settings were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). They embody the results of a systematic review of all available clinical and scientific evidence pertaining to the treatment of unipolar depressive disorders and offer practical recommendations for general practitioners encountering patients with these conditions. The guidelines cover disease definition, classification, epidemiology and course of unipolar depressive disorders, and the principles of management in the acute, continuation and maintenance phase. They deal primarily with biological treatment (including antidepressants, other psychopharmacological and hormonal medications, electroconvulsive therapy, light therapy).

Efficacy and safety of desvenlafaxine succinate in the treatment of major depressive disorder

Venlafaxine is a serotonin–norepinephrine-reuptake inhibitor (SNRI) with a well-established efficacy, safety and tolerability profile. Desvenlafaxine succinate is the succinate salt monohydrate of O-desmethylvenlafaxine, an active metabolite of venlafaxine, and, like its parent compound, is an SNRI. A sustained-release form of desvenlafaxine succinate 100 mg/day has demonstrated efficacy for the treatment of adult major depressive disorder in large multicenter trials. Desvenlafaxine succinate has a good overall safety and tolerability profile, with adverse effects comparable with those of other SNRIs. The most frequent side effects of desvenlafaxine succinate include nausea, dry mouth, constipation, dizziness, insomnia, somnolence, anorexia and sweating. The primary advantage of the sustained-release formulation over other SNRIs based on current information is related to its minimal metabolism via the cytochrome P450 (CYP450) pathway and its minimal impact on CYP450 enzyme systems. Its low potential for drug–drug interactions may have significant clinical relevance, especially in depression associated with medical comorbidities.

Use of Depression Education Materials to Improve Treatment Compliance of Primary Care Patients

In a collaborative effort between a managed behavioral health organization, a health maintenance organization, and a state employer, this pilot study tested the value of mailing a depression education flyer to primary care patients who were recently prescribed antidepressant medications and an informational letter to their physician. The intervention, designed to improve use of behavioral healthcare services and antidepressant medication adherence, had a moderate impact on consistency of antidepressant medication use and on use of psychotherapy in combination with antidepressant medications. Additionally, intervention patients on combination treatment were more likely to stay on antidepressant medications into the continuation phase of treatment.

Antidepressants and psychotherapy: a clinical research review

This review focuses on information concerning antidepressants and psychotherapy in the treatement of both acute and chronic forms of unipolar depression in the English language literature. In it, we address the use of combination therapy, both from the outset of treatment and in a variety of sequences, ie, we examine the potential advantages of adding a targeted psychotherapy to an incompletely effective pharmacotherapy and the potential advantages of adding pharmacotherapy to an incompletely effective psychotherapy The number of research reports available to address these questions is small relative to their importance for clinical practice. There is a clear need for more information about the relative efficacy of pharmacotherapy-psychotherapy combinations or sequences versus either pharmacotherapy or psychotherapy provided as monotherapies.

Therapeutic alternatives for difficult-to-treat depression: a narrative review of the state of the evidence

Despite the large number of depressed patients who do not respond to first-line antidepressants, the evidence base of alternate strategies is quite thin. In this article, a simple 5-stage system for categorizing treatment-resistant depression (TRD) is described and the evidence pertaining to the major strategies currently utilized is summarized using four grades, ranging from D (case reports only) to A (multiple positive placebo-controlled trials). It is concluded that the level of evidence supporting many of the contemporary strategies used for TRD (eg, combinations of antidepressants and augmentation with medications such as pindolol, buspirone, or modafinil) is scanty at best. Even the fundamental question concerning "to augment or to switch" is not answerable with available data. It is noted that the best-documented treatments (ie, lithium augmentation, switching to a monoamine oxidase inhibitor, and electroconvulsive therapy) are among the least utilized. This state of affairs will improve with completion of the studies of Systematic Treatment Alternatives to Relieve Depression, a large multicenter study of difficult-to-treat depression funded by the National Institute of Mental Health. There is a need for greater collaboration among academicians and organizations, such as the American Psychiatric Association, the National Institute of Mental Health, and the pharmaceutical industry, to ensure that sufficient research is conducted so that clinician's choices for patients with TRD can be guided by empirical evidence.

Cost and effectiveness of venlafaxine extended-release and selective serotonin reuptake inhibitors in the acute phase of outpatient treatment for major depressive disorder

OBJECTIVE

The purpose of this retrospective analysis was to estimate the cost and effectiveness of venlafaxine extended-release (VXR) compared with selective serotonin reuptake inhibitors in the outpatient treatment of major depressive disorder.

METHODS

Pooled data from 8, 8-week, randomized, double-blind studies comparing treatment of major depressive disorder with venlafaxine/venlafaxine XR (n = 851), selective serotonin reuptake inhibitors (fluoxetine, paroxetine, fluvoxamine; n = 748), or placebo (4 studies; n = 446) were retrospectively analyzed to determine the economic implications of symptom remission from the perspective of a US third party payer and that of an employer. A decision modeling approach was used to determine cost and effectiveness ratios.

RESULTS

Patients on VXR were associated with 22.8 depression-free days versus 18.6 depression-free days with the studied selective serotonin reuptake inhibitors, based on the decision model. Productive and quality-adjusted days were also expected to increase for VXR patients (22.06 vs. 19.34 and 4.56 to 9.36 vs. 3.72 to 7.63), as was the percentage of patients achieving full activity (25.9% vs. 19.6%). The expected cost per patient achieving remission of symptoms was US 1303.94 dollars and US 1514.96 dollars, and the cost per depression-free days was US 25.66 dollars and US 28.25 dollars, for the VXR and selective serotonin reuptake inhibitors groups, respectively.

CONCLUSIONS

Treatment with VXR is not only expected to increase the rate of remission of symptoms but is also associated with achievement of full activity, higher number of depression-free days, productive days, and quality-adjusted days. VXR is a cost-effective treatment option for major depressive disorder.

Sequenced treatment alternatives to relieve depression (STAR*D): rationale and design

STAR*D is a multisite, prospective, randomized, multistep clinical trial of outpatients with nonpsychotic major depressive disorder. The study compares various treatment options for those who do not attain a satisfactory response with citalopram, a selective serotonin reuptake inhibitor antidepressant. The study enrolls 4000 adults (ages 18-75) from both primary and specialty care practices who have not had either a prior inadequate response or clear-cut intolerance to a robust trial of protocol treatments during the current major depressive episode. After receiving citalopram (level 1), participants without sufficient symptomatic benefit are eligible for randomization to level 2 treatments, which entail four switch options (sertraline, bupropion, venlafaxine, cognitive therapy) and three citalopram augment options (bupropion, buspirone, cognitive therapy). Those who receive cognitive therapy (switch or augment options) at level 2 without sufficient improvement are eligible for randomization to one of two level 2A switch options (venlafaxine or bupropion). Level 2 and 2A participants are eligible for random assignment to two switch options (mirtazapine or nortriptyline) and to two augment options (lithium or thyroid hormone) added to the primary antidepressant (citalopram, bupropion, sertraline, or venlafaxine) (level 3). Those without sufficient improvement at level 3 are eligible for level 4 random assignment to one of two switch options (tranylcypromine or the combination of mirtazapine and venlafaxine). The primary outcome is the clinician-rated, 17-item Hamilton Rating Scale for Depression, administered at entry and exit from each treatment level through telephone interviews by assessors masked to treatment assignments. Secondary outcomes include self-reported depressive symptoms, physical and mental function, side-effect burden, client satisfaction, and health care utilization and cost. Participants with an adequate symptomatic response may enter the 12-month naturalistic follow-up phase with brief monthly and more complete quarterly assessments.

Background and rationale for the sequenced treatment alternatives to relieve depression (STAR*D) study

Sequenced Treatment Alternatives to Relieve Depression (STAR*D) attempts to fill in major clinical information gaps and to evaluate the theoretical principles and clinical beliefs that currently guide pharmacotherapy of major depressive disorder. The study is conducted in representative participant groups and settings using clinical management tools that easily can be applied in daily practice. Outcomes include clinical outcomes and health care utilization and cost estimates. Research findings should be immediately applicable to, and easily implemented in, the daily primary and specialty care practices. This article provides the overall rationale for STAR*D and details the rationale for key design, measurement, and analytic features of the study.

Group Cognitive-Behavioral Treatment of Depression and the Interaction of Demographic Variables

Response levels of 92 depressed subjects with differing demographic profiles to a standardized small-group CBT intervention were examined. Findings were based on combined groups wherein adults participated in 12 two-hour skill-building sessions conducted in 8-week periods. Participants were assessed for levels of depression, hopelessness, anxiety, and social adjustment at pre- and post-test, and 1, 6, 12, 18, and 24 months following treatment. The intervention was effective in the treatment of unipolar depression for all groups, and demographic variables were found to have various significant functional relationships with treatment outcome. Gender combined with marital status, and the separate results of education level, employment status, and income level all indicate different treatment effects.

Relationships between psychosocial factors and abusive parenting attitudes in low-income single mothers

BACKGROUND

Linkages among family violence, maternal mental health, and parenting attitudes are not clearly understood.

OBJECTIVE

To investigate the relationships of abuse (childhood and/or partner), everyday stressors, self-esteem, depressive symptoms, and anger with abusive parenting attitudes.

METHOD

Cross-sectional analysis of data collected in interviews with 53 low-income, single mothers from wave two of a 3-wave study. A conceptual framework and bivariate correlations guided a series of multiple regressions to identify the best predictors for each variable.

RESULTS

A high prevalence of abuse, depressive symptoms, and abusive parenting attitudes was found. Few women had ever received mental health treatment. Abuse (partner and childhood physical) predicted higher everyday stressors which in turn predicted lower self-esteem. Childhood abuse and lower self-esteem predicted more depressive symptoms. More depressive symptoms were related to higher levels of state anger. More everyday stressors and more depressive symptoms predicted higher levels of trait anger. Higher levels of anger expression were associated with higher everyday stressors and lower self-esteem. The presence of partner abuse best predicted higher levels of overall abusive parenting attitudes and more parent-child role reversal. Less parental empathy was associated with higher levels of state anger.

CONCLUSIONS

This study partially explains the relationships of maternal abuse history and mental health status with parenting attitudes. Other predictors of parenting attitudes remain to be identified. The findings underscore the need for healthcare providers to consider the mental health status and abuse histories of low-income, single mothers. The potential disturbance in the parenting process of single mothers in abusive relationships warrants further investigation.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 1: Acute and continuation treatment of major depressive disorder

These practice guidelines for the biological treatment of unipolar depressive disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal for developing these guidelines was to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating patients with these conditions. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for depressive disorders, as well as from meta-analyses and reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into four levels of evidence (A-D). This first part of the guidelines covers disease definition, classification, epidemiology and course of unipolar depressive disorders, as well as the management of the acute and continuation-phase treatment. These guidelines are primarily concerned with the biological treatment (including antidepressants, other psychopharmacological and hormonal medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of young adults and also, albeit to a lesser extent, children, adolescents and older adults.

Venlafaxine and treatment-resistant depression

Treatment-resistant depression (TRD) is an important clinical problem. This paper briefly reviews the definition of TRD and summarizes methodological issues that pertain to treatment research. Recent studies of venlafaxine treatment for TRD also are reviewed. It is concluded that venlafaxine at higher doses is a reasonably well-tolerated and an effective alternative for patients with TRD and typically should be used before tricyclic antidepressants or monoamine oxidase inhibitors. Further research is needed to confirm the prediction that switching a SSRI nonresponder to venlafaxine is a more effective strategy than switching to a second SSRI. The relative merits of switching from a SSRI to venlafaxine versus adding a norepinephrine reuptake inhibitor also warrant careful study.

Identifying an abnormal electroencephalographic sleep profile to characterize major depressive disorder

There is little agreement as to the best definition of a categorically abnormal electroencephalographic (EEG) sleep profile to characterize major depressive disorder. Therefore, a series of classification, replication, and validation analyses were conducted to identify such a profile. The EEG sleep studies of healthy controls (n = 44), depressed inpatients (n = 44), and depressed outpatients (n = 181) were utilized, including subgroups of patients studied both before and after nonpharmacologic treatment with either cognitive behavior therapy (CBT) or interpersonal psychotherapy (IPT). A discriminant index score (based on reduced REM latency, increased REM density, and decreased sleep efficiency) was found to: 1) reliably discriminate between depressed inpatients, depressed outpatients, and controls; 2) show good test-retest reliability; and 3) identify a subset of depressed outpatients who were older, manifested a broader array of EEG sleep disturbances, and were less responsive to CBT or IPT. Posttreatment studies of patients indicated that normal sleep profiles were relatively stable, whereas abnormal profiles tended to normalize. These findings provide an empirically validated method that may improve the applicability, efficiency, and prognostic utility of EEG sleep studies of depressed patients.

The role of Axis II comorbidity in the management of patients with treatment-resistant depression

A significant proportion of antidepressant nonresponders have personality disorders. The relationship between antidepressant resistance and personality pathology is far from straightforward, however, and reflects a disproportionate "burden" of negative prognostic correlates, psychosocial risk factors, and problems that compromise effective therapeutic relationships. An important clinical ground rule is to avoid the reductionistic logical tautology that explains antidepressant failure as a consequence of personality disorder and, by implication, that the patient may deserve to suffer. In evaluating antidepressant-resistant patients, identification of pathologic personality traits or disorders may help provide important clues for future trials of both pharmacotherapy and psychotherapy, particularly in combination.

Management of treatment resistance in the depressed geriatric patient

The treatment of depression in geriatric patients is challenging on all levels. Recognition, compliance, medical comorbidity, tolerance of drug regimens, and accessibility of the patient to therapy all represent major clinical problems. Treating depression in elderly, disabled patients requires patience, keen observation skills, and much flexibility. It is critical that these patients trust their physicians and have ready access if problematic side effects develop. In general, when treating patients with a history of failure to respond, the clinician should choose a medication with a tolerable side-effect profile, and persist with it as long as steady, slow gains are being made. Dosages should be maximized to clinical tolerance prior to considering switching agents or augmentation strategies. It is probably wiser to augment than switch if a partial response has been obtained. Particularly among the medically ill elderly, any "lost ground" may be very difficult to replace. All available psychosocial resources should be assessed and brought to bear productively in the treatment context. We are quite far from a full clinical understanding of "treatment resistance" in elderly depressive patients, but the eminent treatability of depression in elderly patients encourages creative exploration of treatment regimens. Rigorous, placebo-controlled studies of representative samples of elderly patients are needed to clarify the diverse interactions among the many pharmacologic agents available to treat resistant/refractory depression in the elderly.