Depending on the definition used, 25% to 40% of all depression is resistant to treatment with a first or second antidepressant agent. Many primary care clinicians and their patients could and would consider advanced levels of psychopharmacologic intervention to overcome this resistance, but up-to-date information on the efficacy, safety, and tolerability of such strategies may be difficult to find. Commonly utilized strategies may be poorly studied or actually lack evidence of efficacy in controlled trials. Older, better evidenced strategies may be less familiar to primary care clinicians whose training did not specifically address the problem of treatment resistance or who have limited access to current psychiatric literature.
Michael E. Thase, M.D., and colleagues offer a supplement focused on definitions, types, and strategies for difficult depressions. J. Craig Nelson, M.D., discusses difficult-to-treat "unipolar" depressions; Paul E. Keck, Jr., M.D., and Susan L. McElroy, M.D., review bipolar depression (often incorrectly diagnosed as "unipolar" in psychiatry and primary care alike); Alan F. Schatzberg, M.D., discusses the problem of psychotic depression and treatment approaches to this under-appreciated entity. Lastly, I attempt to sum up the issues for primary care and recommend that we begin to emphasize bipolar depression recognition, the use of dual reuptake inhibitor antidepressants as first-line agents, and the potential utility of lithium and atypical antipsychotics as augmentations to antidepressants in our setting. Both have mounting evidence of efficacy in the area of treatment resistance and address both "poles" of the mood disorder spectrum. Such therapeutic efficacy is not beyond interested primary care clinicians.
I am certain that this supplement will give our readers much to consider and much to offer their depressed patients.
J. Sloan Manning
Editor in Chief
The Primary Care Companion to the Journal of Clinical Psychiatry