Is there a place for tricyclic antidepressants and subsequent augmentation strategies in obtaining remission for patients with treatment resistant depression?

Major depressive disorder is a worrying mental health problem and obtaining remission from treatment resistant depression (TRD) remains an important clinical issue. Twenty patients (14 women, 6 men) considered as treatment resistant after the fourth step of a seven-step treatment algorithm to obtain remission in major depression received clomipramine 150 mg/day for 1 month (step 5). In case of failure, two subsequent augmentation strategies with lithium and lithium plus triiodothyronine (T3) were implemented. Median Montgomery-Åsberg Depression Rating Scale (MADRS) score at initiation of clomipramine treatment was 29 (range 8-43). Treatment with clomipramine alone allowed five patients to achieve sustained remission (MADRS ≤8), while three patients were responders (MADRS decrease ≥50%) and three patients were partial responders (MADRS decrease >25%). Lithium augmentation in 10 patients led to one additional remission, whereas no additional remission was observed in 6 patients with further T3 augmentation. Tricyclic antidepressants have demonstrated efficacy in TRD. The present study suggests that treatment with clomipramine might allow obtaining remission in some patients who do not fully respond despite multiple interventions.