Guidelines’ recommendations for the treatment-resistant depression: A systematic review of their quality Journal Articles uri icon

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  • Introduction Depression is a serious and widespread mental health disorder. A significant proportion of patients with depression fail to remit after two antidepressant treatment trials, a condition named treatment-resistant depression (TRD). Clinical practice guidelines (CPGs) are instruments aimed to improve diagnosis and treatment. This study objective is to systematically appraise the quality and elaborate a comparison of high-quality CPGs with high-quality recommendations aimed at TRD. Methods and analysis We searched several specialized databases and organizations that develop CPGs. Independent researchers assessed the quality of the CPGs and their recommendations using AGREE II and AGREE-REX instruments, respectively. We selected only high-quality CPGs that included definition and recommendations for TRD. We investigated their divergencies and convergencies as well as weak and strong points. Results Among seven high-quality CPGs with high-quality recommendations only two (Germany’s Nationale Versorgungs Leitlinie–NVL and US Department of Veterans Affairs and Department of Defense–VA/DoD) included specific TRD definition and were selected. We found no convergent therapeutic strategy among these two CPGs. Electroconvulsive therapy is recommended by the NVL but not by the VA/DoD, while repetitive transcranial magnetic stimulation is recommended by the VA/DoD but not by the NVL. While the NVL recommends the use of lithium, and a non-routine use of thyroid or other hormones, psychostimulants, and dopaminergic agents the VA/DoD does not even include these drugs among augmentation strategies. Instead, the VA/DoD recommends ketamine or esketamine as augmentation strategies, while the NVL does not mention these drugs. Other differences between these CPGs include antidepressant combination, psychotherapy as a therapeutic augmentation, and evaluation of the need for hospitalization all of which are only recommended by the NVL. Conclusions High-quality CPGs for the treatment of depression diverge regarding the definition and use of the term TRD. There is also no convergent approach to TRD from currently high-quality CPGs.


  • Gabriel, Franciele Cordeiro
  • Stein, Airton Tetelbom
  • Melo, Daniela de Oliveira
  • Fontes-Mota, Gessica Caroline Henrique
  • dos Santos, Itamires Benício
  • Rodrigues, Camila da Silva
  • Dourado, Andrea
  • Rodrigues, Mônica Cristiane
  • Fráguas, Renério
  • Florez, Ivan
  • Correia, Diogo Telles
  • Ribeiro, Eliane

publication date

  • 2023