Chronic and treatment resistant depression: diagnosis and stepwise therapy.

BACKGROUND: The 12-month prevalence of depression in Europe is approximately 7%; depression becomes chronic in 15-25% of sufferers. One-third to one-half do not respond to an initial trial of drug therapy lasting several weeks.

METHODS: Selective literature review, including consideration of the German National Disease Management Guideline Unipolar Depression.

RESULTS: At the end of an initial trial of treatment with an antidepressant drug, usually lasting four weeks, its efficacy should be evaluated systematically. In case of non-response, the following options have been found useful: measurement of the serum drug level, dose escalation (but not for selective serotonin reuptake inhibitors [SSRIs]), lithium augmentation, the addition of a second-generation antipsychotic (atypical neuroleptic), and any one of several defined combinations of antidepressants. There is no empirical evidence for switching to another antidepressant. Electroconvulsive therapy is the most effective treatment for refractory depression. Cognitive behavioral therapy, interpersonal psychotherapy, psychoanalysis and psychodynamic psychotherapy have also been found useful. The cognitive behavioral analysis system of psychotherapy (CBASP) was developed specifically for the treatment of chronic depression.

CONCLUSION: The structured application of treatments of documented efficacy, in a stepwise treatment algorithm that gives equal weight to drugs and psychotherapy, is the best way to prevent or overcome treatment resistance and chronification.