Treatment-resistant depression

Abstract

Basic criteria for treatment-resistant depression are defined as one primary unipolar depression episode that does not respond to 300 mg of imipramine or an equivalent antidepressant, with a minimum time to response of 6 weeks, assuring good treatment compliance. There are various options for the treatment of these patients, with different scientific evidence. Strategies for the optimization, augmentation, substitution and combination, as well as the use of electroconvulsive therapy are discussed, and specific algorithmic-based recommendations are proposed. Time to therapeutic response in augmentations will be of at least 2 weeks and not greater than 4 weeks. When adding lithium the latent period should be of f4 weeks. Lifelong treatment after a third episode is based on the risk of recurrence over 90% and the risk of autolysis, which is similar in each episode. The recommendation after the first episode, due to the common practice and its theorical duration, is to maintain the treatment for 6 months. However, we recommend a period of time of not less than 9 months, as the extension of the continuation treatment assures the complete management of the episode.