The Pharmacological Treatment of Tricyclic-Resistant Depression: Review and Management Guidelines

Abstract

Despite the introduction of a wide range of antidepressant drugs since the late 1950s, approximately 30-50% of depressed subjects do not respond to these agents. Various treatment strategies, both pharmacological and non-pharmacological, have been proposed for treatment-resistant depression. This paper critically reviews the studies of single and combined pharmacological treatments for tricyclic-resistant patients, with a particular discussion of lithium augmentation. The major inadequacies of these studies have been the frequent lack of definitions of treatment resistance, the heterogeneity of the depressed samples, and the infrequent use of double-blind, placebo-controlled designs. Two central issues, definition of treatment resistance and clinical predictors of response to pharmacological treatments, are discussed in detail. Finally, a suggested guideline for the management of tricyclic-resistant depression is proposed.

The Prince Henry Hospital Mood Disorders Unit

“…In addition to specific pharmacological and ECT studies, such as assessing carbamazepine for treatment-resistant depression (Cullen et al 1991) and ECT practices in Australasia (O'Dea et al 1991), MDU staff have prepared a number of treatment guidelines, including papers on bipolar disorder and pharmacological treatment of tricyclic-resistant depression (Mitchell, 1987), while Tanner & Ball (1989) have prepared a self-help manual focusing on cognitive and behavioural strategies for overcoming depression, and Eyers et al (1993, submitted) have undertaken patient satisfaction studies that, in turn, have suggested modifications to ward and out-patients' procedures.…”