Refractory to Treatment

If despite over 3 months of antidepressant treatment and/or psychotherapy, your patient has had less than 50% drop in PHQ-9 score, then criteria are met for refractory depression.

Could there be any of the following:

Undiagnosed or contributory medical condition?

Another psychiatric condition or issue such as
  • Psychosis?
  • Bipolar?
  • Alcohol / substance use issues?
    • Consider asking questions from the AUDIT-C
    • Consider giving the AUDIT-C for the patient fill out
  • Domestic violence? Consider using the 4-item HITS
  • Past history of abuse/trauma?
  • Sexual identity or orientation issues?

Any particular psychosocial issues (e.g. relationship, work, school) that might be contributing?

Any other factors?