Management of Treatment Refractory Unipolar Depression

Established: July 2008

Convenor (Chair): Professor Nicol Ferrier, Regional Affective Disorder Service, Newcastle University and Northumbria, Tyne and Wear Trust (contact details: i.n.ferrier@ncl.ac.uk)

Membership
Professor Nicol Ferrier (covenor), Regional Affective Disorder Service, Newcastle University and Northumbria, Tyne and Wear Trust.
Dr Hamish McAllister-Williams, Reader in Psychopharmacology and Professor Jan Scott, Professor of Psychological Medicine, Newcastle University and Regional Affective Disorder Service, Newcastle.
Dr David Christmas and Dr Rob Durham (Clinical Psychology), Dundee University and Ninewells Hospital, Dundee.
Dr David Baldwin, Reader in Psychiatry and Professor Paul Chadwick (Professor of Clinical Psychology), University of Southampton.
Dr Ian Anderson, Senior Lecturer, Manchester University.
Ms Carol Paton (Pharmacy), Oxleas Trust, SE London.
Professor Phil Cowen and Mrs Rena Hockney (Nurse Specialist), University of Oxford, Warneford Hospital, Oxford.
Dr Tony Cleare, Professor Anne Farmer and Dr Catherine Donaldson (Clinical Psychology), Kings College London and Maudsley Hospital.
Professor Tony Hale, University of Kent.
Dr Andre Malizia, University of Bristol.
Dr Ian Jones, University of Cardiff.
Ms Anne Garland (Nurse/CBT therapist), Nottingham.
Dr Elaine McColl, Director, Newcastle Clinical Trials Unit, Newcastle University.
Ms Caroline Murphy, Clinical Trials Unit Manager, Mental Health and Neurosciences Clinical Trials Unit, Institute of Psychiatry, King’s College, London.

Remit and aims
This group comprises clinicians leading Tertiary/Regional Affective Disorder Services in the UK. Each of these Services receives a large number of referrals for patients with treatment refractory depression each year. Clinicians involved in these Services met in Newcastle in October 2007. The meeting focussed on the establishment of minimum datasets to be collected across groups, together with a discussion of the measures to be adopted for staging treatment resistant depression and for evaluating clinical outcomes. Treatment resistant depression is conventionally defined as the failure to respond to two adequate courses of antidepressants given for an adequate period of time. However, the vast majority of patients seen by these Services have received multiple previous pharmacological and psychological treatments and can be defined as being treatment refractory (Thase and Rush (1997) stages IV and V. The group intends to focus on research with the aim of establishing better patient outcomes. There is little evidence available on how to manage this patient group, and in particular how to select particular interventions for patients with particular symptom profiles.

Clinical importance of the topic
Unipolar depression is a major public health issue. Depression is ranked second in the list of disorders in terms of disability – in large part due to treatment resistance and the inadequate state of knowledge as to how to manage this disorder. The suicide rate is high. Approximately 10% of patients develop treatment refractory depression. Given the high prevalence of major depression, the numbers of patients with treatment refractory depression are very high. Research provides little information on how to manage patients who do not respond to their first and second antidepressant treatments, although there is some evidence for cognitive-behaviour therapy (CBT) and the addition of lithium or atypical antipsychotics. However, there is very little information on the place of these therapies or on next steps beyond them.