When do you choose to switch to antidepressants vs augmentation in treatment-resistant depression?

When I approach depression that has been resistant to many antidepressant trials, I consider the following:

First, I reassess the diagnosis. This includes considering comorbidities such as menopause symptoms, ED symptoms, exacerbation of chronic medical issues, and onset of MNCD. I ensure I have considered personality and coping style contributions. I reassess for SUD or changes in substance-use patterns and I assess adherence to medications.

Second, if other contributing factors are not clearly...

Treatment-resistant depression has been profoundly rare in my private practice over the past 34 years. Most patients with the diagnosis of treatment-resistant depression that I see aren't really depressed. They have a pessimistic explanatory style which doesn't respond to any medications. If they do, indeed, have a pessimistic explanatory style, I recommend that my patients read Martin Seligman's book "The Optimistic Child". Others with a diagnosis of treatment-resistant depression have bipolar ...

If the first antidepressant at full therapeutic doses, and after sufficient time to maximize its efficacy, has shown partial benefit, I would most likely not taper and stop it, but rather use a second-generation antipsychotic medication.

If, however, I thought there could be some elements of bipolar disorder, I would consider a mood stabilizer.

If I thought they had subclinical hypothyroidism, I would test TSH, Free T3, and Free T4, and then add Synthroid.

For my much older patients, if most of ...

Treatment-resistant depression is an interesting condition. I would first do a thorough interview, get extensive collateral, and try to do a good differential before thinking about treatment options. Is this TRD or undiagnosed bipolar depression or bipolar 1 or 2 starting as depression before having mania/hypomania eventually?

My considerations to call this bipolar instead of TRD:

1. Age of onset
2. Family history
3. Any suicide attempts or family history of suicide attempts
4. Impulsive, risk-taking behav...