TRD Survey and Expert Consensus Guidelines from Asia
Out on PubMed, from a group of TRD experts, is this paper:
Management of Treatment-Resistant Depression in Real-World Clinical Practice Settings Across Asia.
Neuropsychiatr Dis Treat. 2020 Dec 3;16:2943-2959. doi: 10.2147/NDT.S264813. eCollection 2020.PMID: 33299316
The abstract is copied below:
Purpose: Consensus is lacking on the management of treatment-resistant depression (TRD), resulting in significant variations on how TRD patients are being managed in real-world practice. A survey explored how clinicians managed TRD across Asia, followed by an expert panel that interpreted the survey results and provided recommendations on how TRD could be managed in real-world clinical settings.
Methods: Between March and July 2018, 246 clinicians from Hong Kong, Japan, Mainland China, South Korea, and Taiwan completed a survey related to their treatment approaches for TRD.
Results: The survey showed physicians using more polytherapy (71%) compared to maintaining patients on monotherapy (29%). The most commonly (23%) administered polytherapy involved antidepressant augmentation with antipsychotics that 19% of physicians also indicated as their most important approach for managing TRD. The highest number of physicians (34%) ranked switching to another class of antidepressants as their most important approach, while 16% and 9% chose antidepressant combinations and electroconvulsive therapy (ECT), respectively.
Conclusion: Taking into account the survey results, the expert panel made general recommendations on the management of TRD. TRD partial-responders to antidepressants should be considered for augmentation with second-generation antipsychotics. For non-responders, switching to another class of antidepressants ought to be considered. TRD patients achieving remission with acute treatment should consider continuing their antidepressants for at least another 6 months to prevent relapse. ECT is a treatment consideration for patients with severe depression or persistent symptoms despite multiple adequate trials of antidepressants. Physicians should also consider the response, tolerability and adherence to the current and previous antidepressants, the severity of symptoms, comorbidities, concomitant medications, preferences, and cost when choosing a TRD treatment approach for each individual patient.
The pdf is here.
And from the text:
Physicians were asked under what
clinical scenarios/circumstances they would consider using
ECT and the frequency of ECT use.“Severity of symptoms” emerged as a salient theme raised among physicians
who used ECT. Some mentioned prescribing ECT for TRD
patients who are “highly treatment-resistant”, “unresponsive” and/or demonstrate “poor tolerability to pharmacotherapy”, at “high risk of relapse/recurrence”, display “catatonic symptoms” and/or “food refusal”. ECT was also
considered useful when a “quick response is needed”; for
example, in patients with “suicidal ideation or behavior”.
Most Asian physicians used ECT for <5 patients per year.
A few used ECT for ≥10 patients per year. Only one
physician cited about 30 patients per year. Of the physicians who did not routinely use ECT, most of them did not
recommend its use; with the rest endorsing ECT but had
“limited access”. Physicians’ concerns related to ECT use
included “difficulty in obtaining patient/family consent”
(for “hospitalization” and/or “anesthesia”) as well as postECT “cognitive impairment” and “(patient) psychological
trauma”.
The safety and effectiveness of ECT for depression has
been well-established since 1941. However, access to
ECT remains a challenge for many countries, including
those in Asia. A systematic review showed that globally,
under half of all psychiatric institutions within the same
country provided ECT. Survey results of 334 psychiatric
facilities across 29 Asian countries revealed that ECT was
available only in 257 institutions (77%) across 23 countries (79%). Around 42% of ECT conducted was for schizophrenia and 32% for MDD.64 The World Health
Organization (WHO) recommends that ECT should only
be administered with anesthesia and muscle relaxation. The lack of access to anesthesia and anesthesiologists in
some countries further aggravates the limited availability
of ECT. It is not surprising then that only 3% and 9% of
the surveyed physicians used antidepressant-ECT combination (Table 1) and ranked ECT as the most important
approach (Table 3), respectively, for the treatment of TRD.
Despite these limitations, in-line with the APA guidelines,
the National Institute for Health and Care Excellence
(NICE), and the Canadian Network for Mood and
Anxiety Treatments (CANMAT) guidelines, ECT remains
an important treatment option for depression in various
clinical scenarios, including severe depressive episodes
and medication treatment failures.
This paper is part of a large, multi-faceted project with a survey of Asian psychiatrists and subsequent development of expert consensus guidelines. Of course, this is mostly about pharmacotherapy.
The good news is that ECT gets a reasonable amount of mention in the paper and is given some gravitas. The less good news is the usual low level of usage and mention of accessibility problems. Of note is the fact that schizophrenia is the predominant diagnosis, a well-known feature of Asian ECT practice.
If you have an interest in non-ECT TRD management, then by all means read this paper in its entirety (about 30 minutes).
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