In a study published in The Journal of Clinical Psychiatry, the authors worked with a structured, case-based consensus process. They applied it to assess treatment options for a patient who failed to achieve remission after repeated adequate antidepressant trials. Using a modified Delphi method, 10 Mayo Clinic psychiatrists ranked treatment strategies across a base clinical vignette and half a dozen common variations, such as older age, substance use disorder, metabolic disease, cardiovascular disease, seizure history, and drug intolerance.
New Mayo Clinic guidance stresses patient-specific care, while recent studies examine cannabis use among veterans, while another rejects slashing the DSM-5-TR mixed-features threshold.
Mayo Clinic Reconsiders What Comes Next
A panel of psychiatrists at the Mayo Clinic Depression Center has outlined preferred “next-step” treatments for patients with treatment-resistant depression. In short, their practical guidance fills the gaps left by existing clinical standards.
For the base case, the panel achieved strong consensus on a trio of preferred next-step options:
- Augmentation with a second-generation antipsychotic,
- Transcranial magnetic stimulation (TMS), and
- Ketamine (or esketamine).
Notably, the landmark STAR*D trial didn’t include any of these interventions, underscoring how treatment paradigms have evolved. Patient characteristics, naturally, dictated recommendations.
For older adults, electroconvulsive therapy joined TMS and antipsychotic augmentation as top options.
In patients with substance use disorder, the panel favored TMS or non-addictive pharmacologic strategies. Their guidance advised against the use of ketamine.
Metabolic or cardiovascular disease steered recommendations away from antipsychotics toward weight-neutral or neuromodulatory treatments.
The authors insist that TRD care can’t rely solely on rigid algorithms. Instead, they argue, treatment selection should integrate patient-specific risks, comorbidities, tolerability, access, and preferences. It’s a contention that strives to bring clinical judgment back to the center of decision-making in treatment-resistant depression.
IN OTHER PSYCHIATRY AND NEUROLOGY NEWS
- The Primary Care Companion for CNS Disorders documents a pair of case reports that demonstrate the potential for intermittent theta burst transcranial magnetic stimulation to rapidly reverse treatment-resistant depression in patients with Parkinson disease.
- JCP also reported this week on a new study of depressed patients that failed to support lowering the DSM-5-TR diagnostic threshold for the mixed features specifier from three to two criteria.
- Another PCC case study recounts the story of a 32-year-old woman who’d received a bipolar affective disorder diagnosis who developed a curious lithium-induced rash.
- JCP has published a national study that found that U.S. veterans’ cannabis use varies sharply by region, with the highest rates concentrated in Pacific states.
- And, finally, a new analysis warns that the large language models that power AI could upend global mental health care.
