title: The clinical meaning of refractory depression: a review for the clinician.
abstract: OBJECTIVE
  The authors' goal is to address the complex issue of treatment-refractory depression from a clinical perspective.
  
  
  METHODS
  They review the literature on the major clinical and methodological issues involved in the treatment and study of treatment-refractory depression as well as primary and tertiary care surveys of patients whose depression has not responded to treatment.
  
  
  RESULTS
  There are methodological problems in defining treatment-refractory depression and in the tertiary care surveys of treatment-refractory depression. The authors define treatment-refractory depression as primarily involving diagnostic-treatment variables rather than patient variables. They articulate these variable as a series of questions the clinician may consider when confronted with patients who are considered refractory: 1) Is the diagnosis correct? 2) Has the patient received adequate treatment? 3) Was a rational stepped-care approach used? 4) How was outcome measured? 5) Is there a coexisting medical or psychiatric disorder that interferes with response to treatment? and 6) Are there factors in the clinical setting that are interfering with treatment?
  
  
  CONCLUSIONS
  The problem of treatment-refractory depression has to do primarily with the diagnostic-treatment process than with patient variables. This has a number of implications in the areas of training, education, research, and public health. The evidence indicates that improvements in the recognition and treatment of depression are needed.
authors.affiliation: Affective Disorders Program, Hamilton Psychiatric Hospital, Ontario, Canada.
authors.forename: R
authors.initials: R
authors.lastname: Guscott
authors.forename: P
authors.initials: P
authors.lastname: Grof
mesh_terms: D000928:Antidepressive Agents / Q000627:therapeutic use; D003866:Depressive Disorder / Q000175:diagnosis* / Q000523:psychology / Q000628:therapy; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D004565:Electroconvulsive Therapy; D006801:Humans; D008996:Monoamine Oxidase Inhibitors / Q000627:therapeutic use; D010043:Outcome and Process Assessment, Health Care; D010349:Patient Compliance
chemical_list: D000928:Antidepressive Agents; D008996:Monoamine Oxidase Inhibitors