R H McAllister-Williams1, C Arango2, P Blier3, K Demyttenaere4, P Falkai5, P Gorwood6, M Hopwood7, A Javed8, S Kasper9, G S Malhi10, J C Soares11, E Vieta12, A H Young13, A Papadopoulos14, A J Rush15. 1. Northern Centre for Mood Disorders, Newcastle University, UK; Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK. Electronic address: hamish.mcallister-williams@newcastle.ac.uk. 2. Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), CIBERSAM, School of Medicine, Universidad Complutense, Madrid, Spain. 3. Royal Ottawa Institute of Mental Health Research, University of Ottawa, Canada. 4. University Psychiatric Center KU Leuven, Faculty of Medicine KU Leuven, Belgium. 5. Clinic for Psychiatry and Psychotherapy, Ludwig Maximilian University, Munich, Germany. 6. CMME, Hopital Sainte-Anne (GHU Paris et Neurosciences). Paris-Descartes University, INSERM U1266, Paris, France. 7. University of Melbourne, Melbourne, Australia. 8. Faculty of the University of Warwick, UK. 9. Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria. 10. The University of Sydney, Faculty of Medicine and Health, Northern Clinical School, Department of Psychiatry, Sydney, New South Wales, Australia; Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW 2065 Australia; CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW 2065 Australia. 11. University of Texas Health Science Center, Houston, TX, USA. 12. Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain. 13. Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London & South London and Maudsley NHS Foundation Trust, UK. 14. Somerset Partnership NHS Foundation Trust, UK. 15. Duke University School of Medicine, Durham, NC, USA; Texas Tech University Health Sciences Center, Permian Basin, Midland, TX, USA; Duke-NUS Medical School, Singapore.
Abstract
BACKGROUND: Many depressed patients are not able to achieve or sustain symptom remission despite serial treatment trials - often termed "treatment resistant depression". A broader, perhaps more empathic concept of "difficult-to-treat depression" (DTD) was considered. METHODS: A consensus group discussed the definition, clinical recognition, assessment and management implications of the DTD heuristic. RESULTS: The group proposed that DTD be defined as "depression that continues to cause significant burden despite usual treatment efforts". All depression management should include a thorough initial assessment. When DTD is recognized, a regular reassessment that employs a multi-dimensional framework to identify addressable barriers to successful treatment (including patient-, illness- and treatment-related factors) is advised, along with specific recommendations for addressing these factors. The emphasis of treatment, in the first instance, shifts from a goal of remission to optimal symptom control, daily psychosocial functional and quality of life, based on a patient-centred approach with shared decision-making to enhance the timely consideration of all treatment options (including pharmacotherapy, psychotherapy, neurostimulation, etc.) to optimize outcomes when sustained remission is elusive. LIMITATIONS: The recommended definition and management of DTD is based largely on expert consensus. While DTD would seem to have clinical utility, its specificity and objectivity may be insufficient to define clinical populations for regulatory trial purposes, though DTD could define populations for service provision or phase 4 trials. CONCLUSIONS: DTD provides a clinically useful conceptualization that implies a search for and remediation of specific patient-, illness- and treatment obstacles to optimizing outcomes of relevance to patients.
BACKGROUND: Many depressedpatients are not able to achieve or sustain symptom remission despite serial treatment trials - often termed "treatment resistant depression". A broader, perhaps more empathic concept of "difficult-to-treat depression" (DTD) was considered. METHODS: A consensus group discussed the definition, clinical recognition, assessment and management implications of the DTD heuristic. RESULTS: The group proposed that DTD be defined as "depression that continues to cause significant burden despite usual treatment efforts". All depression management should include a thorough initial assessment. When DTD is recognized, a regular reassessment that employs a multi-dimensional framework to identify addressable barriers to successful treatment (including patient-, illness- and treatment-related factors) is advised, along with specific recommendations for addressing these factors. The emphasis of treatment, in the first instance, shifts from a goal of remission to optimal symptom control, daily psychosocial functional and quality of life, based on a patient-centred approach with shared decision-making to enhance the timely consideration of all treatment options (including pharmacotherapy, psychotherapy, neurostimulation, etc.) to optimize outcomes when sustained remission is elusive. LIMITATIONS: The recommended definition and management of DTD is based largely on expert consensus. While DTD would seem to have clinical utility, its specificity and objectivity may be insufficient to define clinical populations for regulatory trial purposes, though DTD could define populations for service provision or phase 4 trials. CONCLUSIONS: DTD provides a clinically useful conceptualization that implies a search for and remediation of specific patient-, illness- and treatment obstacles to optimizing outcomes of relevance to patients.
Authors: Péter Döme; Péter Kunovszki; Péter Takács; László Fehér; Tamás Balázs; Károly Dede; Siobhán Mulhern-Haughey; Sébastien Barbreau; Zoltán Rihmer Journal: PLoS One Date: 2021-01-20 Impact factor: 3.240
Authors: Iris Dalhuisen; Filip Smit; Jan Spijker; Iris van Oostrom; Eric van Exel; Hans van Mierlo; Dieuwertje de Waardt; Martijn Arns; Indira Tendolkar; Philip van Eijndhoven Journal: BMC Psychiatry Date: 2022-02-05 Impact factor: 3.630