A systematic review of all studies (controlled and uncontrolled) to evaluate psychological interventions with treatment-resistant depression. One systematic review and two subsequent RCTs including persons 58 years or older with all grades of depressive disorders showed that tricyclic antidepressants, SSRIs, or MAOIs reduced the proportion of persons who did not recover over 28 to 51days compared with placebo.

Background:

About 30% of people with depression do not respond to an antidepressant at the recommended dose and can be described as having treatment-refractory depression.

?Chronicity of Major Depressive Disorder involves many interacting variables

?Resistance to anti-depressant medications

Research issues:

?Definitions used for ?treatment resistance?

?Under treatment leading to ?pseudo-resistance?

?Inconsistencies in defining ?non-response?

?Lack of RCTs / controlled studies

?To examine the effectiveness of psychological treatment interventions for treatment-resistant depression including all controlled and uncontrolled designs

Inclusion Criteria:

?Failure to respond to at least one previous trial of anti-depressant pharmacotherapy

?Participants 18 and above

??Talking treatments? used as a central component

?Any design and language

Exclusion Criteria:

?Failure to explicitly show non-response to medications in participants prior to study intervention

?Absence of diagnostic criteria fulfillment for depression ( >14 on HRSD or >19 for Beck Depressive Inventory)

?National Health Services (NHS) Centre for Research and Dissemination guidelines for conduct of systematic reviews

?Journals hand-searched (duration mentioned)

?Websites

?Researchers in the field contacted (grey literature)

?Terms ?depression? and ?psychological?,? depression? and ?psychotherapy?, ?refractory? and ?depression?, ?chronic? and ?depression?, ?resistant? and ?depression?

?Language Bias

?Methodological quality was not used for exclusion

?Use of checklist (next slide)

?Publication bias was addressed ? using grey literature

?Data extraction was done by one reviewer and checked by second

?Sample size

?Checklist for assessing quality of both randomized and non-randomized health care intervention studies developed by Downs and Black 1998

?Maximum score 32

?Score <12 indicates poor quality

?The checklist is as follows:

?Reporting (10 points)

?External Validity (3 points)

?Internal Validity ? Bias (7 points)

?Internal Validity (confounding) ? Selection Bias (6 points)

?Power (1 point)

?Are the results clearly displayed?

What are the results?

Method of establishing treatment resistance ? few used prospective design

?Heterogeneity with respect to group of medicines received

?Study setting (Inpatient / Outpatient)

?Treatment duration / follow-up variable

?Statistical tests used (only one used ANOVA)

?Only 2 relatively poor RCTs of psychological treatments for treatment-resistant depression are identified

?Methodological issues

?Comparison used Cognitive Therapy

Conclusions:

There is little evidence to guide the management of depression that has not responded to a course of antidepressants. Treatment-refractory depression is an important public health problem and large pragmatic trials are needed to inform clinical practice.