Look for zebras

It was standing-room only at an APA session called ‘Management of treatment-resistant depression: the art and the science’ probably because the presenter, Dr Charles Nemeroff, is an engaging speaker with a very witty repartee. Giggles aside – here is what we captured as of interest to all of those involved in managing patients with depression.

Patients with major depressive disorders that appear not to respond to antidepressant therapy are a broad group. According to Dr Nemeroff*, as many as 25% these patients are incorrectly labelled as having treatment-resistant depression. He said there are some patients for whom it is a case of finding the right treatment and ensuring the treatment is given at an adequate dose. Patients like these are not strictly-speaking treatment-resistant but may be fast metabolisers, may be slow responders, or may respond better to an antidepressant of a different class.

Dr Nemeroff also reminded his audience that non-response to treatment might be a sign that depression is secondary to another, occult or undisclosed disorder requiring correction and management. This could include occult substance or alcohol abuse and he advised exploring possible cause not only with the patient but also through talking with family and partners if relevant. He also said failure to respond well to an antidepressant in some cases should prompt review of the psychiatric diagnosis. As he put it: “if you hear the sound of hoofs and can’t see any horses – look for zebras”.

Giving it time

Taking the time in consultations to talk to all patients about their antidepressant therapies is crucial, according to Dr Nemeroff. He said that another very common reason for apparent treatment failure can be non-adherence. And he had some tips for delegates. He said that rather than covering potential adverse effects of treatment right at the end of a consultation, clinicians should cover that topic earlier, so that the patient doesn’t leave an appointment with their head full of the potential downsides of treatments rather than the potential benefits.

Dr Nemeroff also advised that once patients with depression are in remission, psychotherapy – which he described as being a real biological intervention – offers another tool to help keep them there.

He had lots of advice on a plethora of options and ways to manage patients who could be described as having treatment-resistant depression and used a patient case example to interact with the audience and hear their thoughts on patient management.

The session ran over time as delegates lined up with questions about myriad practical aspects of patient care – showing that APA interactive sessions are just that.

*Dr Nemeroff is the Leonard M. Miller Professor and Chair, Department of Psychiatry and Behavioural Sciences at the University of Miami, Miller School of Medicine, Florida.

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