Synopsis
Verify whether treatment has truly been adequate, revisit diagnosis and barriers, use shared stepwise switching or augmentation with specialist monitoring, and build relapse prevention from residual symptoms, recurrence history and the person's priorities.
- Define the current episode, residual symptoms and function and list every psychological and medication trial with dose, duration, adherence, benefit, harm and reason for stopping.
- Reassess bipolar disorder, psychosis, trauma, substance use, neurodevelopment, personality-related needs, pain, sleep, endocrine disease and social adversity before escalation.
- Confirm that psychological treatment was accessible, formulation matched, adequately delivered and attended; referral or a few sessions is not an adequate trial.
Key red flags
The label treatment resistant should not be applied before confirming diagnosis, bipolarity, adequate dose and duration, adherence, therapy delivery, substances, physical illness and social barriers.
Investigation priorities
Verify medication dose, duration, adherence and harm and psychological modality, delivery, attendance and formulation fit.
Management branches
Depression has not improved sufficiently after one or more interventions.
- Reconstruct symptoms, function and every medicine and therapy trial with dose, duration, adherence, delivery, benefit and harm.
- Reassess bipolarity, comorbidity, substances, physical causes and social or access barriers and correct remediable factors.
Key medicines
VortioxetineUse 10 mg orally once daily in adults under 65, adjusting between 5 and 20 mg daily by response; start 5 mg once daily from age 65.
Lithium augmentationInitiate and adjust under specialist-informed care to a 12-hour serum level usually at least 0.4 mmol/L and not above 1.0 mmol/L, using lower ranges when clinically appropriate.