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2. Defining and Assessing Treatment-Resistant Depression
Prof. Philip Cowen
Professor of Psychopharmacology
Department of Psychiatry
University of Oxford, UK

3. Defining treatment-resistant depression

4. Definition: industry trials
Failure to respond to two separate antidepressant trials

5. Assessing treatment-resistant depression

6. In practice: individual assessment
Treatment history:
Number of medications
Psychological treatments
Course: how long the condition has been going on
Impingement on coping resources
Symptomatology level
Disability
Ability to work
Social life
Level of treatment resistance

7. In practice: individual assessment
Treatment history:
Number of medications
Psychological treatments
Course: how long the condition has been going on
Impingement on coping resources
Symptomatology level
Disability
Ability to work
Social life
Level of treatment resistance

8. In practice: individual assessment
Treatment history:
Number of medications
Psychological treatments
Course: how long the condition has been going on
Impingement on coping resources
Symptomatology level
Disability
Ability to work
Social life
Level of treatment resistance

9. In practice: individual assessment
Treatment history:
Number of medications
Psychological treatments
Course: how long the condition has been going on
Impingement on coping resources
Symptomatology level
Disability
Ability to work
Social life
Level of treatment resistance

10. Bipolar spectrum conditions
Is it major depression?
Diagnostic aspects
Comorbid anxiety
Substance abuse
Comorbidities
Standard antidepressant treatment: not as effective
Bipolar spectrum conditions

11. Bipolar spectrum conditions
Is it major depression?
Diagnostic aspects
Comorbid anxiety
Substance abuse
Comorbidities
Standard antidepressant treatment: not as effective
Bipolar spectrum conditions
Vázquez GH, Tondo L, Undurraga J, et al (2014) Pharmacological treatment of bipolar depression. Advances in Psychiatric Treatment, 20: 193–201.

12. Negative thinking vs psychotic symptom
Depressive psychosis
Negative thinking vs psychotic symptom
Antidepressant monotherapy
Rarely successful
Antipsychotic drug fully dosed
As if treating a psychosis
Good response

13. Negative thinking vs psychotic symptom
Depressive psychosis
Negative thinking vs psychotic symptom
Antidepressant monotherapy
Rarely successful
Antipsychotic drug fully dosed
As if treating a psychosis
Good response
Wijkstra J, Burger H, Van den Broek WW, et al (2010) Treatment of unipolar psychotic depression: a randomized, double-blind study comparing imipramine, venlafaxine, and venlafaxine plus quetiapine.Acta Psychiatrica Scandinavica, 121: 190–200.

14. Negative thinking vs psychotic symptom
Depressive psychosis
Negative thinking vs psychotic symptom
Antidepressant monotherapy
Rarely successful
Antipsychotic drug fully dosed
As if treating a psychosis
Good response
Wijkstra J, Burger H, Van den Broek WW, et al (2010) Treatment of unipolar psychotic depression: a randomized, double-blind study comparing imipramine, venlafaxine, and venlafaxine plus quetiapine.Acta Psychiatrica Scandinavica, 121: 190–200.

15. Key points Consider differential diagnoses:
Psychotic disorders, bipolar spectrum conditions, substance misuse and eating disorders
If you do not see any response after 4 weeks:
Unlikely the patient will improve with that medication

16. Key points Consider differential diagnoses:
Psychotic disorders, bipolar spectrum conditions, substance misuse and eating disorders
If you do not see any response after 4 weeks:
Unlikely the patient will improve with that medication

17. Next Presentation - Strategies: Switching Antidepressants