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Prediction of longer-term outcome of treatment-resistant depression in tertiary care

  • Abebaw Fekadu (a1), Lena J. Rane (a2), Sarah C. Wooderson (a2), Kalypso Markopoulou (a2), Lucia Poon (a3) and Anthony J. Cleare (a4)...
Abstract
Background

Systematic studies on the outcome of treatment-resistant depression are scarce.

Aims

To describe the longer-term outcome and predictors of outcome in treatment-resistant depression.

Method

Out of 150 patients approached, 118 participants with confirmed treatment-resistant depression (unipolar, n= 7; bipolar, n=27; secondary, n=14) treated in a specialist in-patient centre were followed-up for between 8 and 84 months (mean=39, s.d.=22).

Results

The majority of participants attained full remission (60.2%), most of whom (48.3% of total sample) showed sustained recovery (full remission for at least 6 months). A substantial minority had persistent subsyndromal depression (19.5%) or persistent depressive episode (20.3%). Diagnosis of bipolar treatment-resistant depression and poorer social support were associated with early relapse, whereas strong social support, higher educational status and milder level of treatment resistance measured with the Maudsley Staging Method were associated with achieving quicker remission. Exploratory analysis of treatment found positive associations between treatment with a monoamine oxidase inhibitor (MAOl) in unipolar treatment-resistant depression and attaining remission at discharge and at final follow-up, and duloxetine use predicted attainment of remission at final follow-up.

Conclusions

Although many patients with treatment-resistant depression experience persistent symptomatology even after intensive, specialist treatment, most can achieve remission. The choice of treatment and presence of good social support may affect remission rates, whereas those with low social support and a bipolar diathesis should be considered at higher risk of early relapse. We suggest that future work to improve the long-term outcome in this disabling form of depression might focus on social interventions to improve support, and the role of neglected pharmacological interventions such as MAOIs.

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Copyright
Corresponding author
Abebaw Fekadu, Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, PO Box 9086, Addis Ababa, Ethiopia. Email: abe.wassie@kcl.ac.uk
Footnotes
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Declaration of interest

A.J.C. has within the past 9 years: received honoraria for consulting and/or speaking from Eli Lilly, UCB Pharma, Merck, Organon, Pfizer and Cyberonics; received unrestricted research grant support from GlaxoSmithKline; and has written medico-legal reports on patients with depression for court proceedings instructed by both claimants and defendants.

Footnotes
References
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Prediction of longer-term outcome of treatment-resistant depression in tertiary care

  • Abebaw Fekadu (a1), Lena J. Rane (a2), Sarah C. Wooderson (a2), Kalypso Markopoulou (a2), Lucia Poon (a3) and Anthony J. Cleare (a4)...
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eLetters

Outcome of treatment resistant depression

MOHINDER KAPOOR, Locum Consultant Old Age Psychiatry
05 December 2012

Fekadu et al 1 should be congratulated for presenting useful information in relation to an important and under researched issue of longer - term outcome and predictors of outcome in treatment resistant depression. The authors concluded that social support influences the outcome of treatment resistant depression.

However, I have few reservations in relation to the identification offactors that may increase the likelihood of non-response to antidepressanttreatment. The authors of this study rightly looked at factors like gender, early or late age of onset, severity of illness, and chronicity ofcourse. However they failed to highlight the factors like the presence of a comorbid psychiatric or general medical disorder in patients with depression. The presence of a comorbid psychiatric disorder increases the likelihood of treatment-resistant depression. Often, these comorbid disorders are missed or are suboptimally treated, and they can confound both the evaluation and treatment of the depression2.

Substance abuse is another factor that further complicates the evaluation of treatment-resistant depression. A detailed patient history and collateral history for substances of abuse are important in the evaluation process of treatment-resistant depression for two reasons. First, acute and chronic effects of substances may cause or worsen depressive symptoms, affect compliance, and contribute to treatment resistance. Even moderate usage of alcohol has been shown to contribute totreatment resistance3. Second, the presence of a mood disorder increases the likelihood of a substance use disorder or makes the patient more proneto relapse4.

General medical conditions and their treatments may either cause or worsen depression. It has been reported that unrecognized medical illness prompts psychiatric admission and exacerbates psychiatric symptoms in nearly half of psychiatric inpatients5. Many patients labelled with treatment resistant depression have an organic cause that may be uncoveredduring the evaluation process. Endocrine disorders, such as hypothyroidism, Cushing's disease, and Addison's disease, have received the most attention. However, other medical conditions, including diabetes,coronary artery disease, cancer, HIV infection, Parkinson's disease and pain should also be considered6,7. It will be necessary for future studiesto take into account the factors mentioned above.

Declaration of interest: None

References:1.Fekadu A et al. Prediction of longer - term outcome of treatment - resistant depression in tertiary care. Br J Psychiatry 2012; 201: 369-3752.Keitner GI, Ryan CE, Miller IW, et al. 12-month outcome of patients with major depression and co morbid psychiatric or medical illness (compound depression). Am J Psychiatry 1991;148:345-350.3.Castaneda R, Sussman N, Westreich L, et al. A review of the effects of moderate alcohol intake on the treatment of anxiety and mood disorders. J Clin Psychiatry. Vol 57(5), May 1996, 207-212 4.Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse. JAMA 1990; 264:2511-25185.Hall RCW, Gardner ER, Popkin MK, et al. Unrecognized physical illness prompting psychiatric admission: a prospective study. Am J Psychiatry, 1981; 138:5;629-635 6.Franco-Bronson K. The management of treatment-resistant depression in the medically ill. Psychiatr Clin North Am 1996; 19(2):329-349.7.Evans DW, Staab JP, Petitto JM, et al. Depression in the medical setting: biopsychological interaction and treatment considerations. J ClinPsychiatry 1999; 60 [suppl 4]:40-55

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Conflict of interest: None declared

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