How to manage a patient with chronic treatment-resistant major depressive disorder?

Clinical Documentation for Treatment-Resistant Major Depressive Disorder

Diagnostic Confirmation and Definition

Document that the patient meets criteria for treatment-resistant depression (TRD), defined as failure to respond (<50% reduction in symptom severity) to at least two adequate antidepressant trials with different mechanisms of action in the current depressive episode. 1

• Each trial must have been administered at minimum effective dosage for at least 4 weeks duration to qualify as an adequate trial 2, 1
• Discontinuation due to side effects before completing 4 weeks should not be counted as a treatment failure 2, 1
• For prolonged current episodes, only treatment failures within the last 2 years should be considered when establishing TRD 2, 1
• Document the specific antidepressants tried, their dosages, duration of each trial, and the patient's adherence to treatment 3

Structured Documentation Using Staging Tools

Use the Maudsley Staging Method (MSM) for structured documentation, as it is the preferred staging instrument with prospective validation and correctly predicts treatment resistance in >85% of cases. 2, 1

The MSM incorporates:

• Number of treatment failures 2
• Duration of current illness episode 2
• Baseline symptom severity 2
• Augmentation strategies previously attempted 2
• Prior electroconvulsive therapy (ECT) treatment history 2
• The MSM produces a single score ranging from 3 to 15, with higher scores indicating greater treatment resistance 3

Alternative documentation tools include the Antidepressant Treatment History Form (ATHF), which has good reliability and predictive validity particularly for ECT studies 3, 2

Clinical Note Structure

Chief Complaint and History of Present Illness

• Document the duration of the current depressive episode 3
• Specify all depressive symptoms including depressed mood, anhedonia, weight/appetite changes, sleep disturbances, psychomotor changes, fatigue, worthlessness/guilt, concentration difficulties, and suicidal ideation 3
• Note the severity of functional impairment in occupational, social, and self-care domains 3, 1

Treatment History Documentation

Document each prior antidepressant trial with the following details:

• Medication name and class (SSRI, SNRI, TCA, etc.) 3
• Maximum dosage achieved 3
• Duration of treatment at therapeutic dose 3
• Patient adherence to the regimen 3
• Response achieved (quantify using percentage symptom reduction or standardized scales) 1
• Reason for discontinuation (lack of efficacy vs. side effects) 2, 1
• Any augmentation strategies attempted (lithium, thyroid hormone, antipsychotics) 3

Assessment and Diagnosis

Use ICD-10 codes F32.x (single episode) or F33.x (recurrent) for major depressive disorder, as TRD lacks a dedicated diagnostic code. 2

• Explicitly state in the clinical narrative that the patient meets criteria for treatment-resistant depression 2
• Document the MSM score or alternative staging assessment 2, 1
• Specify any depression specifiers present: melancholic, atypical, anxious, psychotic, or mixed features 1
• Critical pitfall: Rule out bipolar depression, as it requires mood stabilizers as foundation, not antidepressants alone 1

Current Symptom Severity Assessment

Use standardized rating scales for objective documentation:

• Montgomery-Åsberg Depression Rating Scale (MADRS-10) as the preferred clinician-administered instrument 3
• Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR) as the preferred patient-reported measure 3
• Patient Health Questionnaire-9 (PHQ-9) or Hamilton Depression Rating Scale (HAM-D) are acceptable alternatives 3
• Clinical Global Impression (CGI) scale for overall psychiatric status 1
• Document suicidality assessment explicitly 3, 1

Treatment Plan

For confirmed TRD, augmentation with atypical antipsychotics represents the primary first-line FDA-approved strategy with the most extensive evidence base. 1, 4, 5

Specific FDA-approved options include:

• Aripiprazole augmentation (first medication specifically FDA-approved for adjunctive treatment of TRD) 1, 4
• Olanzapine-fluoxetine combination (starting dose: 5mg olanzapine with 20mg fluoxetine once daily in evening; dose range: 5-20mg olanzapine with 20-50mg fluoxetine) 1, 4
• Quetiapine augmentation 1, 4

Document the rationale for selecting the specific augmentation strategy based on:

• Prior treatment response patterns 6
• Side effect profile and patient tolerability concerns 4, 6
• Metabolic risk factors (particularly relevant for olanzapine) 1, 4
• Patient preference through shared decision-making 6

Alternative first-line augmentation strategies with strong evidence:

• Lithium augmentation 1, 6
• Liothyronine (T3) augmentation 1, 6
• Bupropion combination 1, 4, 6
• Lamotrigine 1, 6
• Tricyclic antidepressant or mirtazapine combination 1, 6

For highly refractory cases who have failed multiple augmentation strategies, document consideration of:

• Esketamine or ketamine 1, 4, 6
• Transcranial Magnetic Stimulation (TMS), particularly when medication side effects limit options 2, 1
• Electroconvulsive Therapy (ECT) for severe, refractory cases 3, 1

Psychotherapy Integration

• Document concurrent cognitive behavioral therapy in conjunction with pharmacotherapy 2, 1
• Note that psychotherapy should not be used as monotherapy in confirmed TRD 1

Monitoring Plan

Establish specific monitoring parameters:

• Depressive symptom severity using MADRS or HAM-D at regular intervals 1
• Functional impairment and quality of life measures 3, 1
• Suicidality assessment at each visit 3, 1
• Medication adherence verification 1
• Metabolic monitoring (weight, glucose, lipids) when using atypical antipsychotics 1, 4
• Drug interaction monitoring, particularly with fluoxetine's long half-life and cytochrome P450 enzyme inhibition 2, 4

Treatment Goals

The goal of treatment is remission (complete symptom resolution), not just response. 1

• Define remission as MADRS score ≤10 or HAM-D score ≤7 3
• Document target timeline for reassessment (minimum 4 weeks at adequate dosage before declaring treatment failure) 2, 1
• Specify functional recovery goals beyond symptom reduction 3

Critical Documentation Pitfalls to Avoid

• Do not count medication discontinuation due to side effects before 4 weeks as treatment failure 2, 1
• Do not exclude consideration of treatment options based solely on number of prior medication failures 1
• Do not escalate antidepressant doses beyond minimum effective dosage, as most studies show no benefit with increased risk of side effects 4
• Do not overlook bipolar depression, which requires different treatment approach 1
• Do not declare treatment failure before completing at least 4 weeks at adequate dosage 2, 1, 4