A retrospective examination of care pathways in individuals with treatment-resistant depression

Abstract

Background Individuals with treatment-resistant depression (TRD) experience a high burden of illness. Current guidelines recommend a stepped care approach for treating depression, but the extent to which best-practice care pathways are adhered to is unclear. Aims To explore the extent and nature of ‘treatment gaps’ (non-adherence to stepped care pathways) experienced by a sample of patients with established TRD (non-response to two or more adequate treatments in the current depressive episode) across three cities in the UK. Method Five treatment gaps were considered and compared with guidelines, in a cross-sectional retrospective analysis: delay to receiving treatment, lack of access to psychological therapies, delays to medication changes, delays to adjunctive (pharmacological augmentation) treatment and lack of access to secondary care. We additionally explored participant characteristics associated with the extent of treatment gaps experienced. Results Of 178 patients with TRD, 47% had been in the current depressive episode for >1 year before initiating antidepressants; 53% had received adequate psychological therapy. A total of 47 and 51% had remained on an unsuccessful first and second antidepressant trial respectively for >16 weeks, and 24 and 27% for >1 year before medication switch, respectively. Further, 54% had tried three or more antidepressant medications within their episode, and only 11% had received adjunctive treatment. Conclusions There appears to be a considerable difference between treatment guidelines for depression and the reality of care received by people with TRD. Future research examining representative samples of patients could determine recommendations for optimising care pathways, and ultimately outcomes, for individuals with this illness.

Care pathways for people with major depressive disorder: A European Brain Council Value of Treatment study

“…The UK: One study of MDD-diagnosed participants identified a referral rate of 21% to secondary care over 3 years, [43], although rates as low as 5 and 6% [63, 75] have been reported. One study of people with TRD identified a rate of 44%, but acknowledged a likely overestimation [55].…”

“…Patient variability: Certainly, the characteristics of patients included in the studies reviewed impact the extent of treatment gaps. Those with more severe depression are more likely to receive diagnosis, treatment, follow-up, and specialist care [55]. As such, if we had limited our synthesis to those with moderate or severe depression, the treatment gaps would likely have been much smaller, although the quantity of evidence would have been much smaller.…”

“…The UK: One study reported an average of 8 years between mental illness onset and first healthcare contact in people with depression/anxiety [54], while within-episode (in a TRD cohort) indicated that almost half had been in episode for over 2 years before beginning antidepressant treatment [55].…”

The Downstaging Concept in Treatment-Resistant Depression: Spotlight on Ketamine

“…Another one is not starting adjunctive therapies such as lithium and atypical antipsychotics after two unsuccessful antidepressant trials, which again confirms the great need for improvement in the treatment of TRD. The authors also point out the lack of guideline standardization concerning the sequence, the number of steps, and the assessment of the best moment to go to another step [ 27 ]. The progressive course of TRD is presented graphically on Figure 1 .…”

Patient perspectives of lithium and quetiapine augmentation treatment in treatment-resistant depression: A qualitative assessment

“…Both lithium and quetiapine are recommended by most major treatment guidelines ( Taylor et al, 2020 ), but the existing evidence does not favour one over the other, leading to clinical equipoise ( Bauer et al, 2013 ). However, despite evidence of efficacy and guideline recommendations, augmentation is underused in clinical practice and there remains a proportion of patients who do not find augmentation adequately helpful ( Day et al, 2021 ).…”