Treatment and response in refractory depression: results from a specialist affective disorders service

Background: The best treatment approaches for chronic severe refractory depression remain uncertain. This study aimed to identify short-term outcome and most successful somatic treatments of severe refractory depressives referred to an affective disorders service. Methods: Patients with chronic refractory depression referred to a specialist affective disorders service over a 10-year period were studied. Using detailed case records of the index episode, courses of treatment and outcome were examined. Results: Patients were predominantly middle-aged females with few prior episodes but long index episodes. Patients received higher antidepressant doses and more combinations on the specialist service. Very-high-dose antidepressants (tricyclics, velafaxine or tricyclic–MAOI combinations), usually augmented with lithium and often combined with ECT, were the most effective somatic treatments. Most subjects improved substantially, but few reached premorbid levels. Limitations: The study was retrospective. Treatment courses were sequential rather than random. Conclusions: Refractory depression is responsive to vigorous somatic therapy, although most patients continue with some symptoms.