SYMPOSIA

[PS-17]
Symposium Title: Overcoming treatment resistance: An update
Treatment strategies for treatment resistant depression
Selçuk Aslan
Gazi University, Medical School, Psychiatry Department, Ankara, Turkey
E-mail: saslan@gazi.edu.tr
Bulletin of Clinical Psychopharmacology, Vol: 21, Supplement: 2, 2011 - www.psikofarmakoloji.org
Abstracts of the Invited Speakers
Depression is a disorder with heterogenic etiology and variable clinical features. Response to the treatment is defined as a 50% reduction
in admission symptoms. Recent studies with large numbers of patients have revealed that acute phase treatment should last for 6 weeks,
including at least 4 weeks with effective dosages. Approximately 60% of patients have a response to the first antidepressant treatment.
The remainder, 40% of patients, either has a partial response or they are non-responders (Fava 1996).
At the end of 6 weeks with optimum treatment dosing, if symptoms have not reduced by 20-25%, patients are described as nonresponders
and drug treatment should be switched to another type of antidepressant medication. Patients, who do not respond to
trials of adequate dosages and periods of two or more different classes of antidepressant treatments, are considered as treatmentresistant
depression (TRD). If there is a partial response to antidepressant treatment, waiting for couple of weeks is the rational approach.
The patients who have high depression scores at the initial evaluation have relatively higher degrees of partial or non-response to
antidepressant medications. These cases are more likely to have comorbid axis 1 and axis 3 physical disorders. An 8-12 week period of
effective antidepressant treatment should be applied in these cases. Thase and Rush, proposed 5-stage-model for the description of TRD
(1997). Later in the STAR D study, Rush et al. developed sequences of treatment alternatives for relieving depression (Rush et al. 2003).
On the other hand, increasing drug dosages results in more side effects and adverse reactions. Some patients may be low metabolizers
and higher doses may result in significant side effects. Also fast metabolizer patients may respond to higher doses of medications. Efficacy
of atypical antipsychotics, stimulants, pindolol, lithium, and lamotrigine have been tested for augmentation in ongoing treatment for TRD
in clinical trials (Caravalho et al 2009). In severe cases with no response or partial response to treatment, inpatient treatment should be
considered.
Non-responders or partial responders can be treated with electro convulsive therapy with anesthesia or non-responders can be treated
with rTMS (Paul et al 2006). Selected non-responsive cases may be treated with more invasive techniques such as deep brain stimulation
or vagus nerve stimulation. Biological predictors should be identified to irecognize patients who will not respond to two adequate trials
of different antidepressant.
In addition, psychotherapeutic interventions during the treatment period, such as observing and revealing automatic thoughts,
assumptions, and basic beliefs and depressive schemas, should be evaluated and behavioral and cognitive interventions can be applied.
Activity scheduling and participating in regular exercise might also be helpful to some degree.
Key words: Depression, treatment resistant depression
Bulletin of Clinical Psychopharmacology 2011;21(Suppl. 2):S85
Treatment resistant psychiatric disorders and trauma history
Mehmet Akif Ersoy
Ege University School of Medicine, Department of Psychiatry, Izmir, Turkey
E-mail: akifersoy@gmail.com
Although many clinicians depending on their experience will agree that childhood trauma history will cause treatment resistance
regardless of the diagnosis, studies investigating this issue directly are scarce. During our search of literature we have found publications
on the relationship between childhood trauma and treatment resistance in a few disorders such as obsessive compulsive disorder (OCD),
major depression, and bipolar affective disorder. One study reported that 82% of OCD cases had a history of childhood trauma. In this
study 39% of the cases met the criteria for post traumatic stress disorder (PTSD) and half of those who had a history of trauma met the
PTSD criteria. It is noticeable that those who had major depression or borderline personality disorder, in addition to OCD, had a higher
risk of having comorbid PTSD. Treatment resistant OCD cases should be screened for PTSD and having comorbid major depression and/
or borderline personality disorder helps to predict PTSD and may help to determine the severity of the illness.
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