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Identifying Difficult-to-Treat Depression: Differential Diagnosis, Subtypes, and Comorbidities

Bradley N. Gaynes, MD, MPH

Published: November 15, 2009

Article Abstract

Treatment-resistant depression (TRD) is a common clinical presentation responsible for much of the burden of major depressive disorder worldwide. For this reason, TRD requires aggressive identification and management. Although several models have been proposed to describe TRD,consensus is still needed on the criteria (ie, dose, duration,compliance, number of trials required) used to define treatment response and resistance. When diagnosing patients with depression,clinicians should identify risk factors associated with treatment resistance, including clinical subtypes of depression and medical or psychiatric comorbidities that could affect the course of treatment.When evaluating a patient who has not responded to a first course of antidepressant treatment, the clinician should verify the primary diagnosis and ensure that the patient has adhered to a treatment regimen that was of adequate dose and duration.

From the Department of Psychiatry and the UNCRegional Center for STAR*D,University of North Carolina School of Medicine, ChapelHill.

This article is derived from the planning teleconference series"Tackling Partial Remission to Depression Treatment," which was held inMarch and April 2009 and supported by an educational grant fromBristol-Myers Squibb Company and Otsuka America Pharmaceutical,Inc.

DrGaynes is a consultant for Bristol-Myers Squibb and has receivedgrant/research support from the National Institute of Mental Health, the Agency for Healthcare Research and Quality, M3 Corporation, Bristol-Myers Squibb, and Novartis.

Corresponding author: Bradley Gaynes, MD, MPH, University of NorthCarolina School of Medicine, 101 Manning Dr, Chapel Hill, NC 27514(

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