Definition, Assessment, and Staging of Treatment—Resistant Refractory Major Depression: A Review of Current Concepts and Methods
Open accessAbstract
Objective Up to 15% of depression patients eventually present with treatment-resistant or refractory depression (TRD), a condition that causes significant social and economic burdens. Our paper aims to summarize the current medical literature on the conceptual and methodologic issues involved in the definition, assessment, and staging of TRD. Method We reviewed the recently published medical literature to identify papers that specifically discuss TRD. For this, we searched MEDLINE, EMBASE, and PsycINFO for potentially relevant English-language articles published between January 1996 and June 2006. Results Recent methodologic and conceptual advances have contributed to the achievement of an acceptable level of theoretical consensus on the general meaning of TRD. Accordingly, depression is usually considered resistant or refractory when at least 2 trials with antidepressants from different pharmacologic classes (adequate in terms of dosage, duration, and compliance) fail to produce a significant clinical improvement. Regarding diagnostic assessments, an accurate and systematic evaluation should be made to elicit the potential role of several contributing factors, such as medical and psychiatric comorbidity. Conclusion Recently, 3 staging methods for TRD have been described, but they currently require extensive empirical support. Future research on TRD should include prospective studies addressing the validity of the proposed criteria, the impact of depression comorbid with othe…
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Almost 60% of patients fail to recover after undergoing one antidepressant trial.
“It is reported that almost 60% of patients fail to recover after undergoing one antidepressant trial,320–322”
From Epigenetic regulation in major depression and other stress-related disorders: molecular mechanisms, clinical relevance and therapeutic potential (2023) · cites this paper as [320]
Cites
Hamilton, M. (1960) · Journal of Neurology, Neurosurgery & Psychiatry · doi:10.1136/jnnp.23.1.56 · Cited by 32,817 · see citing works
The Long-term Natural History of the Weekly Symptomatic Status of Bipolar I Disorder
Judd, L. L., Akiskal, H. S., Schettler, P. J., Endicott, J., Maser, J., Solomon, D. A., Leon, A. C., Rice, J. A., & Keller, M. B. (2002) · Archives of General Psychiatry · doi:10.1001/archpsyc.59.6.530 · Cited by 2,106 · see citing works
Report by the ACNP Task Force on Response and Remission in Major Depressive Disorder
Rush, A. J., Kraemer, H. C., Sackeim, H. A., Fava, M., Trivedi, M. H., Frank, E., Ninan, P. T., Thase, M. E., Gelenberg, A. J., Kupfer, D. J., et al. (2006) · Neuropsychopharmacology · doi:10.1038/sj.npp.1301131 · Cited by 707 · cited 2× · see citing works
“Not achieving remission despite adequate treatment usually results in the presence of residual depressive symptoms (for example, insomnia, fatigue, psychic or somatic anxiety, and excessive reactivity to social stress) that have consistently been shown to be associated with poorer outcomes, increased risk of relapse,…”
BackgroundMethodIs bipolar disorder still underdiagnosed? Are antidepressants overutilized?
Ghaemi, S. N., Sachs, G. S., M. Chiou, A., Pandurangi, A. K., & Goodwin, F. K. (1999) · Journal of Affective Disorders · doi:10.1016/s0165-0327(98)00076-7 · Cited by 376 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
Malhi, G. S., & Mann, J. J. (2018) · The Lancet · doi:10.1016/s0140-6736(18)31948-2 · Cited by 4,099 · see citing works
Otte, C., Gold, S. M., Penninx, B. W., Pariante, C. M., Etkin, A., Fava, M., Mohr, D. C., & Schatzberg, A. F. (2016) · Nature Reviews Disease Primers · doi:10.1038/nrdp.2016.65 · Cited by 2,269 · see citing works
Lefaucheur, J.-P., André-Obadia, N., Antal, A., Ayache, S. S., Baeken, C., Benninger, D. H., Cantello, R. M., Cincotta, M., de Carvalho, M., De Ridder, D., et al. (2014) · Clinical Neurophysiology · doi:10.1016/j.clinph.2014.05.021 · Cited by 2,119 · see citing works
Kennedy, S. H., Lam, R. W., McIntyre, R. S., Tourjman, S. V., Bhat, V., Blier, P., Hasnain, M., Jollant, F., Levitt, A. J., MacQueen, G. M., et al. (2016) · The Canadian Journal of Psychiatry · doi:10.1177/0706743716659417 · Cited by 1,150 · see citing works
Inflamed moods: A review of the interactions between inflammation and mood disorders
Rosenblat, J. D., Cha, D. S., Mansur, R. B., & McIntyre, R. S. (2014) · Progress in Neuro-Psychopharmacology and Biological Psychiatry · doi:10.1016/j.pnpbp.2014.01.013 · Cited by 609 · see citing works
Clinical utility and prospective of TMS–EEG
Tremblay, S., Rogasch, N. C., Premoli, I., Blumberger, D. M., Casarotto, S., Chen, R., Di Lazzaro, V., Farzan, F., Ferrarelli, F., Fitzgerald, P. B., et al. (2019) · Clinical Neurophysiology · doi:10.1016/j.clinph.2019.01.001 · Cited by 472 · see citing works
Resting-state functional connectivity in treatment-resistant depression
Lui, S., Wu, Q., Qiu, L., Yang, X., Kuang, W., Chan, R. C. K., Huang, X., Kemp, G. J., Mechelli, A., & Gong, Q. (2011) · American Journal of Psychiatry · doi:10.1176/appi.ajp.2010.10101419 · Cited by 336 · see citing works
Staging of Mental Disorders: Systematic Review
Cosci, F., & Fava, G. A. (2013) · Psychotherapy and Psychosomatics · doi:10.1159/000342243 · Cited by 235 · see citing works
Yuan, M., Yang, B., Rothschild, G., Mann, J. J., Sanford, L. D., Tang, X., Huang, C., Wang, C., & Zhang, W. (2023) · Signal Transduction and Targeted Therapy · doi:10.1038/s41392-023-01519-z · Cited by 246 · see citing works
Nuñez, N. A., Joseph, B., Pahwa, M., Kumar, R., Resendez, M. G., Prokop, L. J., Veldic, M., Seshadri, A., Biernacka, J. M., Frye, M. A., et al. (2022) · Journal of Affective Disorders · doi:10.1016/j.jad.2021.12.134 · Cited by 215 · see citing works
Réus, G. Z., Jansen, K., Titus, S., Carvalho, A. F., Gabbay, V., & Quevedo, J. (2015) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2015.05.007 · Cited by 221 · see citing works
Staging methods for treatment resistant depression. A systematic review
Ruhé, H. G., van Rooijen, G., Spijker, J., Peeters, F. P. M. L., & Schene, A. H. (2012) · Journal of Affective Disorders · doi:10.1016/j.jad.2011.02.020 · Cited by 210 · see citing works
Eisendrath, S. J., Gillung, E., Delucchi, K. L., Segal, Z. V., Nelson, J. C., McInnes, L. A., Mathalon, D. H., & Feldman, M. D. (2016) · Psychotherapy and Psychosomatics · doi:10.1159/000442260 · Cited by 187 · see citing works
Antidepressant Effects of the Muscarinic Cholinergic Receptor Antagonist Scopolamine: A Review
Drevets, W. C., Zarate, C. A., & Furey, M. L. (2013) · Biological Psychiatry · doi:10.1016/j.biopsych.2012.09.031 · Cited by 195 · see citing works
Zrenner, B., Zrenner, C., Gordon, P. C., Belardinelli, P., McDermott, E. J., Soekadar, S. R., Fallgatter, A. J., Ziemann, U., & Müller-Dahlhaus, F. (2020) · Brain Stimulation · doi:10.1016/j.brs.2019.10.007 · Cited by 175 · see citing works
Deep brain stimulation of the medial forebrain bundle: Distinctive responses in resistant depression
Fenoy, A. J., Schulz, P., Selvaraj, S., Burrows, C., Spiker, D., Cao, B., Zunta-Soares, G., Gajwani, P., Quevedo, J., & Soares, J. (2016) · Journal of Affective Disorders · doi:10.1016/j.jad.2016.05.064 · Cited by 125 · see citing works
Fenoy, A. J., Schulz, P. E., Selvaraj, S., Burrows, C. L., Zunta-Soares, G., Durkin, K., Zanotti-Fregonara, P., Quevedo, J., & Soares, J. C. (2018) · Translational Psychiatry · doi:10.1038/s41398-018-0160-4 · Cited by 118 · see citing works
Blumberger, D. M., Mulsant, B. H., Fitzgerald, P. B., Rajji, T. K., Ravindran, A. V., Young, L. T., Levinson, A. J., & Daskalakis, Z. J. (2012) · The World Journal of Biological Psychiatry · doi:10.3109/15622975.2011.579163 · Cited by 118 · see citing works
Sackeim, H. A., Aaronson, S. T., Bunker, M. T., Conway, C. R., Demitrack, M. A., George, M. S., Prudic, J., Thase, M. E., & Rush, A. J. (2019) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2019.03.021 · Cited by 109 · see citing works
Standardisation framework for the Maudsley staging method for treatment resistance in depression
Fekadu, A., Donocik, J. G., & Cleare, A. J. (2018) · BMC Psychiatry · doi:10.1186/s12888-018-1679-x · Cited by 106 · see citing works
Clinical research challenges posed by difficult-to-treat depression.
Rush, A. J., Sackeim, H. A., Conway, C. R., Bunker, M. T., Hollon, S. D., Demyttenaere, K., Young, A. H., Aaronson, S. T., Dibué, M., Thase, M. E., et al. (2022) · Psychological Medicine · doi:10.1017/s0033291721004943 · Cited by 89 · see citing works
Economic Burden of Treatment-Resistant Depression on the U.S. Health Care System
Sussman, M., O’sullivan, A. K., Shah, A., Olfson, M., & Menzin, J. (2019) · Journal of Managed Care & Specialty Pharmacy · doi:10.18553/jmcp.2019.25.7.823 · Cited by 65 · see citing works
Li, Z., Zhang, Y., Wang, Z., Chen, J., Fan, J., Guan, Y., Zhang, C., Yuan, C., Hong, W., Wang, Y., et al. (2013) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2012.10.003 · Cited by 63 · see citing works
Aberrant cortical neurodevelopment in major depressive disorder
Schmitgen, M. M., Depping, M. S., Bach, C., Wolf, N. D., Kubera, K. M., Vasic, N., Hirjak, D., Sambataro, F., & Wolf, R. C. (2019) · Journal of Affective Disorders · doi:10.1016/j.jad.2018.09.021 · Cited by 53 · see citing works
López-Solà, C., Subirà, M., Serra-Blasco, M., Vicent-Gil, M., Navarra-Ventura, G., Aguilar, E., Acebillo, S., Palao, D. J., & Cardoner, N. (2020) · European Psychiatry · doi:10.1192/j.eurpsy.2020.65 · Cited by 31 · see citing works
Epidemiology of treatment resistant depression among major depressive disorder patients in Israel
Sharman Moser, S., Chodick, G., Gelerstein, S., Barit Ben David, N., Shalev, V., & Stein-Reisner, O. (2022) · BMC Psychiatry · doi:10.1186/s12888-022-04184-8 · Cited by 23 · see citing works
Quest for biomarkers of treatment-resistant depression: Shifting the paradigm toward risk
Smith, D. F. (2013) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2013.00057 · Cited by 22 · see citing works
Maguire, S., Surgenor, L. J., Le Grange, D., Lacey, H., Crosby, R. D., Engel, S. G., Fromholtz, K. M., Bamford, B., & Touyz, S. (2017) · Journal of Eating Disorders · doi:10.1186/s40337-017-0155-1 · Cited by 20 · see citing works
Aibar-Durán, J. Á., Rodríguez Rodríguez, R., de Diego Adeliño, F. J., Portella, M. J., Álvarez-Holzapfel, M. J., Martín Blanco, A., Puigdemont Campos, D., & Molet Teixidó, J. (2022) · Neurosurgery · doi:10.1227/neu.0000000000001739 · Cited by 16 · see citing works
Denee, T., Ming, T., Waller, J., Bailey, T., Rajkovic-Hooley, O., Middleton-Dalby, C., Le, H. H., Zhang, Q., McCrone, P., & Taylor, D. (2021) · Current Medical Research and Opinion · doi:10.1080/03007995.2020.1857580 · Cited by 12 · see citing works
Xie, J., Pu, C., & Sun, M. (2026) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2026.1774549 · Cited by 1 · see citing works
Department of Pharmacology, S. O. P., Zabihi, M., Mehrabadi, S. R. A., Department of Pharmacology, S. O. P., Barkhordari, A., Department of Psychology, F. U., Movahedian, Z., Department of Psychology, F. U., Dastjerdi, G., Department of Psychiatry, S. O. M., et al. (2023) · Romanian Journal of Neurology · doi:10.37897/rjn.2023.1.7
- Authors
- Berlim, M. T., & Turecki, G.
- Affiliations
- Douglas Mental Health University Institute (CA)
- ORCID
- Turecki, Gustavo
- Venue
- The Canadian Journal of Psychiatry
- Publisher
- SAGE Publications
- Published
- 2007-01
- Volume
- 52
- Issue
- 1
- Pages
- 46-54
- ISSN
- 0706-7437 (ISSN-L)
- 1497-0015
- OpenAlex
- W57359236
- Cited by
- 412
- References
- 4
- Citations by year
- 2026: 23 · 2025: 17 · 2024: 22 · 2023: 22 · 2022: 37 · 2021: 30 · 2020: 21 · 2019: 28 · 2018: 20 · 2017: 16 · 2016: 21 · 2015: 23 · 2014: 23 · 2013: 31 · 2012: 18
- FWCI
- 1.43
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The Canadian Journal of Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Pharmacology › Treatment of Major Depression
- Health Sciences › Medicine › Psychiatry and Mental health › Electroconvulsive Therapy Studies
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- treatment-resistant depression, antidepressant trials, comorbidities, psychiatric comorbidity, predictors of treatment outcome
- MeSH terms
- Antidepressive Agents, Tricyclic, Major Depressive Disorder, Dose-Response Relationship, Drug, Drug Resistance, Humans, Imipramine, Patient Compliance, Personality Disorders, Severity of Illness Index, Time Factors, Comorbidity, Prevalence, Randomized Controlled Trials as Topic, Substance-Related Disorders
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review