Treatment-resistant depression (TRD) has a fairly low barrier of entry. Failure of 2 full antidepressant trials—lasting 6 weeks at a minimally effective dose—is enough to qualify. In this month’s issue of TCPR, we’ll highlight pharmacologic advances that are underutilized and debunk a few that are unlikely to be effective for TRD.

You may have read about the meta-analysis published in Lancet earlier this year on the efficacy evidence for all antidepressants (Cipriani A et al, Lancet 2018;391(10128):1357–1366). It’s a complicated paper, and in this article, we’ll take a closer look at it and give you our take on the bottom line.

Over the last decade, several published studies have reported an increased risk of type 2 diabetes associated with antidepressant use in adults. But does the same hold true for children and adolescents?

There’s a lot of discussion in the medical journals about nutritional psychiatry, which is the concept that certain diets can prevent or treat psychiatric disorders (Marx W et al, Proc Nutr Soc 2017;76(4):427-436).

It seems like an endless debate: When a patient does not respond to the first trial of an antidepressant, what should we do? Switch to something else? Augment with another agent? If the latter, how often should that augmenting agent be an atypical antipsychotic?

Ketamine has become increasingly popular as an off-label medication for rapid onset treatment of refractory depression. Recently, the American Psychiatric Association convened a task force to review the data and come up with some recommendations.

How do you start a new patient on antidepressant treatment? We do this countless times in our practices, and reviewing the topic may feel a bit like returning to residency. However, it’s important to revisit our standard operating procedures from time to time to ensure we’re thinking carefully about our decisions during our busy days.

You’ve tried different SSRIs and then some, but your patient either can’t tolerate what you’ve prescribed or simply hasn’t experienced a lift in mood. Now what? Dr. Gitlin has some ideas.

Your patient has now failed four antidepressant medications, both alone and as cocktails. What else can you pull out of your bag of tricks? Dr. Becker suggests considering transcranial magnetic stimulation (TMS), which he maintains is underutilized. “Many of my colleagues right down the hall from me still don’t think of TMS for treatment or don’t know who to refer for it,” he says. “I think it should be more readily considered for a lot of patients out there.”

For a look at how TMS works, how effective it is, how it compares with electroconvulsive therapy (ECT), whether some brands of TMS machines are better than others, and what you have to do to make sure your patient’s health insurance plan picks up the tab, we spoke with Dr. Becker, who prescribes this treatment for some of his patients.