Abstract Body

In this presentation a model for the management of difficult to treat depression (DTD) will be presented based upon a recently published international consensus statement (McAllister-Williams et al. 2020 Journal of Affective Disorders 267:264-282). This model emphasises the goals of: optimal symptom control – remission if possible; optimisation of psychosocial functioning; and optimisation of prophylaxis against relapse/deterioration in mood. Building on these goals, the model follows a number of principles. These include emphasizing the importance of shared decision making and measurement-based care, enhancing engagement and retention in services, self-management strategies and frequent re-assessments, all incorporated in an integrated service pathway. The model itself encompasses eight elements: 1. Optimal symptom control using conventional, guideline recommended, treatments but moving on to treatments beyond guidelines in an appropriate and timely way; 2. Targeting symptoms associated with poor outcomes, e.g. anxiety and pain; 3. Targeting symptoms associated with poor functioning and quality of life such as sleep difficulties, fatigue and cognitive dysfunction; 4. Screening for and managing physical, psychiatric, substance misuse and iatrogenic comorbidities; 5. Optimisation of long-term treatment; 6. Using self-management techniques to empower patients; 7. Using integrated health services to help provide a sense of containment and ensure wide consideration of treatment options; and 8. Establishing regular reviews of the patient’s diagnosis and treatment. Examples of each of these elements will be provided.

Abstract Body

Major depression is a serious, disabling, often chronic or recurrent mental disorder affecting over 350 million people worldwide.

Treatment of major depression is now conceptualized as proceeding through three phases: the acute phase, the continuation phase, and the remission phase. Patients not achieving remission after several treatment trials are defined treatment-resistant, but a debate is ongoing regarding how many trials must fail before a patient can be defined as “treatment-resistant”. It must be acknowledged that depression is a heterogeneous disease, and several personal, socio-cultural and clinical factors should be taken into account in order to develop a personalized management plan for patients with major depression.

A new concept of “difficult to treat depression” has been recently proposed. According to this concept, when a complete control of the disorder is not feasible, the treatment should aim at minimizing the impact of symptoms and the side effects of treatments on patients’ daily lives. Moreover, the concept of difficult to treat depression includes the presence of co-occurring problems/ behaviours/ disorders/ situations, which can worsen the course or management of depression.

The management of patients with treatment resistant depression includes the optimization of disease management, in terms of symptom control, improvement of daily functioning and of quality of life. However, an approach aiming to personalize treatment of patients with major depressive disorder and focused on the specific clinical features of each patient can be valuable for optimizing the treatment of patients with resistant depression.