Carle Foundation Hospital Family Medicine Residency, Urbana, Illinois.
Am Fam Physician. 2024 May;109(5):410-416.
Treatment-resistant depression is defined as absence of remission despite trials of two or more antidepressant medications and can occur in up to 31% of patients with major depressive disorder. Partial response to treatment is defined as less than 50% reduction in depression-rating scores. Before diagnosing treatment-resistant depression or partial response to treatment, adherence to adequate doses and duration of medications should be confirmed. Management strategies include adding psychotherapy, switching antidepressant medication class, or augmenting with additional medications. Current guidelines recommend augmentation with a second-generation antidepressant, an atypical antipsychotic, tricyclic antidepressants, lithium, or a triiodothyronine medication as pharmacologic options. Ketamine and esketamine can also be used as augmentation for treatment-resistant depression and may help reduce suicidal ideation. Electroconvulsive therapy and repetitive transcranial magnetic stimulation may be effective. Pharmacogenetic testing has limited evidence and is not recommended. Nonpharmacologic therapies include psychotherapy, exercise, and focused dietary changes.
治疗抵抗性抑郁症定义为尽管尝试了两种或更多种抗抑郁药物治疗，但仍未缓解，可以发生在多达 31%的重度抑郁症患者中。治疗的部分反应定义为抑郁评分减少不到 50%。在诊断治疗抵抗性抑郁症或治疗部分反应之前，应确认药物的足够剂量和持续时间的依从性。管理策略包括添加心理治疗、转换抗抑郁药物类别或用其他药物增效。目前的指南建议使用第二代抗抑郁药、非典型抗精神病药、三环类抗抑郁药、锂或三碘甲状腺原氨酸药物作为药物选择进行增效。氯胺酮和依他佐辛也可作为治疗抵抗性抑郁症的增效剂，可能有助于减少自杀意念。电惊厥治疗和重复经颅磁刺激可能有效。药物遗传学检测的证据有限，不建议进行。非药物治疗包括心理治疗、运动和有针对性的饮食改变。
