Treatment-resistant depression — structured clinical viva

This is true TRD by common operational criteria: two adequate antidepressant trials failed, pseudo-resistance reasonably excluded. Confirm ongoing risk, residual symptoms, and psychotherapy access. Measurement-based care continues (serial PHQ-9/CGI).^[5]

Lithium is a legitimate unipolar augmenter — not "only for bipolar." STAR*D compared lithium versus T3 after two failed medication treatments. Discuss start-low dosing, serum levels, renal/thyroid monitoring, toxicity education, and teratogenicity if relevant.^[1] T3 and atypical antipsychotic augmentation (e.g. aripiprazole low dose; quetiapine XR) are alternatives with different harm profiles — name metabolic and akathisia monitoring for atypicals.^[6]

ECT should be discussed proactively if severity, melancholia, psychosis, or high suicide risk escalate, and remains appropriate after true pharmacological resistance. Consent covers benefits, cognitive risks, anaesthetic risks, and expected course — frame as a medical procedure, not folklore punishment.^[2]

rTMS has sham-controlled evidence (high-frequency left DLPFC) with better cognitive tolerability than ECT but is not interchangeable with ECT for the most severe psychotic presentations.^[3] Esketamine has TRD trial support with oral antidepressant and requires monitored administration (BP, dissociation); access is specialist and region-dependent — not DIY home treatment.^[4]