Depression

Question 1

What is treatment resistant depression?

Answer 1

No global definition

RANZCP guidelines: no improvement despite adequate trial of two different antidepressants

Question 2

Steps to manage treatment resistant depression?

Answer 2

1. Re-evaluate the diagnosis, comorbidities, adherence
   - If uncertain, second opinion should be sought
2. Review of medication
   - Usual to start with SSRI.
   - If partial response -> consider increasing dose or augmenting, before switching. May augment with mirtazapine, lithium, T3 or atypical antipsychotic.
   - If no response-> consider switching to SNRI, TCA, MAOI.
   - Consider serum levels especially for TCAs.
3. Psychotherapy
4. ECT/TMS

Question 3

What % of patients remit with initial antidepressant treatment?

Answer 3

30%

Question 4

What diagnoses should you consider in a person who is not responding to antidepressant medication?

Answer 4

Bipolar, melancholic and psychotic depression
Anxiety disorder
Personality disorder
Substance misuse

Question 5

Switching to or from a MAOI requires a clean washout period of at least how long?

Answer 5

One week

Up to 5 weeks for fluoxetine

Question 6

How long should a person be kept on antidepressant medication after a depressive episode?

Answer 6

6 months - 1 year (RANZCP CPG)