Toggle Main Menu Toggle Search

Open Access padlockePrints

The identification, assessment and management of difficult-to-treat depression: An international consensus statement

Lookup NU author(s): Professor Hamish McAllister-WilliamsORCiD



This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND).


© 2020Background: Many depressed patients are not able to achieve or sustain symptom remission despite serial treatment trials – often termed “treatment resistant depression”. A broader, perhaps more empathic concept of “difficult-to-treat depression” (DTD) was considered. Methods: A consensus group discussed the definition, clinical recognition, assessment and management implications of the DTD heuristic. Results: The group proposed that DTD be defined as “depression that continues to cause significant burden despite usual treatment efforts”. All depression management should include a thorough initial assessment. When DTD is recognized, a regular reassessment that employs a multi-dimensional framework to identify addressable barriers to successful treatment (including patient-, illness- and treatment-related factors) is advised, along with specific recommendations for addressing these factors. The emphasis of treatment, in the first instance, shifts from a goal of remission to optimal symptom control, daily psychosocial functional and quality of life, based on a patient-centred approach with shared decision-making to enhance the timely consideration of all treatment options (including pharmacotherapy, psychotherapy, neurostimulation, etc.) to optimize outcomes when sustained remission is elusive. Limitations: The recommended definition and management of DTD is based largely on expert consensus. While DTD would seem to have clinical utility, its specificity and objectivity may be insufficient to define clinical populations for regulatory trial purposes, though DTD could define populations for service provision or phase 4 trials. Conclusions: DTD provides a clinically useful conceptualization that implies a search for and remediation of specific patient-, illness- and treatment obstacles to optimizing outcomes of relevance to patients.

Publication metadata

Author(s): McAllister-Williams RH, Arango C, Blier P, Demyttenaere K, Falkai P, Gorwood P, Hopwood M, Javed A, Kasper S, Malhi GS, Soares JC, Vieta E, Young AH, Papadopoulos A, Rush AJ

Publication type: Review

Publication status: Published

Journal: Journal of Affective Disorders

Year: 2020

Volume: 267

Pages: 264-282

Print publication date: 15/04/2020

Online publication date: 07/02/2020

Acceptance date: 06/02/2020

ISSN (print): 0165-0327

ISSN (electronic): 1573-2517

Publisher: Elsevier B.V.


DOI: 10.1016/j.jad.2020.02.023