New drugs , old problems REVISITING . . . PHARMACOLOGICAL MANAGEMENT OF TREATMENT - RESISTANT DEPRESSION

Effective pharmacological management of depression resistant to antidepressant medication is best carried out in the context of a supportive and collaborative relationship, following a mutually agreed care plan. Simpler pharmacological approaches such as switching antidepressant classes are tried first, then augmentation is used if needed. New classes of antidepressants have made antidepressant combination a popular augmentation strategy, but lithium addition has most supporting evidence. The use of atypical antipsychotics as augmenting agents is increasing. For patients unresponsive to these strategies, monoamine oxidase inhibitors and electroconvulsive therapy remain important. Large randomised pragmatic trials are needed to help clinicians and patients make better treatment choices. Philip Cowen is Professor of Psychopharmacology at the Warneford Hospital (University Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX. Tel.: 01865 226394; fax: 01865 251076; e-mail: [email protected]). He is also an honorary consultant psychiatrist at the Warneford and a Medical Research Council clinical scientist. His main interest is in the neurobiology of mood disorders and their treatment. Box 1 Developments in the pharmacological management of treatment-resistant depression • Patients presenting to psychiatrists have usually already received at least two adequate trials of antidepressant medication without response • More antidepressant medications are now available • Treatment focus is on achieving clinical remission • The evidence base of treatment remains poor • Treatment algorithms and guidelines have been developed