Prospective evaluation of specialist inpatient treatment for refractory affective disorders.

BACKGROUND: Little data exist to inform the treatment of severe and resistant affective disorders. We report here the effectiveness of specialist multimodal inpatient treatment for refractory affective disorders. METHODS: Prospective evaluation of 225 consecutive patients admitted to the National Affective Disorders Unit between 2001 and 2008. RESULTS: Patients were highly treatment-resistant: most had already received ECT, lithium augmentation and over 10 prior treatment trials. Even so, sequential assessment with the Hamilton Depression Rating Scale found that 69% showed a clinical response (≥ 50% reduction in Hamilton score) to intensive therapy during admission; 50% continued to sustain a full response and 71% at least a partial response on discharge. Patients' self-ratings (57% very much or much improved, 24% slightly improved) and relative and referrer reports (75% and 68% respectively rated patients as improved) gave similar levels of improvement. LIMITATIONS: This was an observational study, without any untreated control group. The generalisability of the findings is limited by the highly specialised nature of the unit. CONCLUSIONS: Most patients with depression highly resistant to prior treatment respond to specialist and intensive multimodal inpatient therapy.

Depression 2: Exploring management options for adults with moderate to severe symptoms.

The National Institute for Health and Clinical Excellence recently updated its guideline on treating and managing depression in adults. The first part of this two part unit covered the identification, assessment and initial management of persistent subthreshold depressive symptoms and mild to moderate depression. This second part looks at the core treatments for moderate to severe depression, as well as mild to moderate depression and persistent subthreshold symptoms that have not responded to low intensity interventions.

Depression 1: identifying the condition and offering initial treatment for adults.

Nurses must ensure their practice remains up to date and that they are aware of changes in the evidence base for managing depression. This two part unit on the updated National Institute for Health and Clinical Excellence guideline on depression outlines some of the main areas that were updated and the implications for nursing practice.

A multidimensional tool to quantify treatment resistance in depression: the Maudsley staging method.

OBJECTIVE: Treatment resistance is a common clinical phenomenon in depression. However, current unitary models of staging fail to represent its complexity. We aimed to devise a model to stage treatment-resistant depression, taking into account the core factors contributing to treatment failure. METHOD: We reviewed the literature to identify factors consistently associated with treatment resistance. We also analyzed data from a subgroup of patients discharged from a specialist inpatient unit for whom adequate data were obtainable. RESULTS: We present a points-based staging model incorporating 3 factors: treatment, severity of illness, and duration of presenting episode. In this model, the rating of symptom severity ranges from subsyndromal depression (score 1) to severe syndromal depression with psychosis (score 5). Antidepressant treatment is rated on a 5-point subscale based on number of medications used, while duration of the presenting episode is rated on a 3-point subscale. The overall level of resistance estimated using this model varies from minimal resistance (score of 3) to severe resistance (score of 15). The rating system allows the overall severity of treatment resistance to be summarized either as a single numeric score or under a single descriptive category. It may also be possible to specify categories (mild, moderate, and severe) based on severity of resistance. Analysis of inpatient data indicates that the factors incorporated in the model and the model itself have some predictive validity. CONCLUSION: This staging model has reasonable face and predictive validity and may have better utility in staging treatment resistance than currently available methods.