Charles Montano, MD, and Carmen Kosicek, MSN, PMHNP-BC, comment on the impact of various classes of MDD treatments on time to achieve goals and/or response.
Gus Alva, MD, DFAPA: Let me move over to a different theme. I’d like you both to discuss the differences in the time to achieving goals or response with different classes of major depressive disorder treatments. We touched on rapid-acting antidepressants. What are some of advantages of rapid symptom resolution?
Charles Montano, MD: We just started to use the nasal preparations. If someone is really disparaging—it feels like they’re giving up, this has gone on too long, I can’t continue to do this, I have horrible thoughts about not wanting to wake up in the morning, but I will not kill myself—you always have to explore that. When they get quick resolution of those symptoms, they can take a breath of clean air and say, “There’s a hope for me that I will get out from under this blanket of depression.” That’s the beauty of rapid-acting [antidepressants]. Even some of the new GABA-glutamate preparations, neurosteroids, are remarkably quick and very nice to see in clinical research. They’re going to be a wonderful addition. You mentioned the dextromethorphan preparations; new mechanisms; better, quicker ways of getting to the networks that are involved in depression. Having that rapid response gives hope. It reinvigorates life.
Gus Alva, MD, DFAPA: The flip side of not having a rapid effect might be risk of suicide, not adhering to the treatment, more expenditures, and greater disease burden.
Charles Montano, MD: [Patients need] early intervention and quick follow-up. Don’t wait a month after giving an antidepressant. The only reason these folks are taking their medication is because they have faith in you and in the system. Having a phone call once week and having them back in 2 weeks at the most would be the thing to do. Data show that they’re going to have some improvement if they’re going to do well in the long term on the initial antidepressant.
Gus Alva, MD, DFAPA: Carmen, how would you treat a patient who relapsed after stopping their major depressive disorder treatment? Would you get them back on the same treatment that they had before, or would select something new?
Carmen Kosicek, MSN, PMHNP-BC: First, what was it? Was it adverse effects from the medication? Did they change their insurance? Why did they stop? Were they too flat? What was the reason? Maybe they’ll say, “No, I was fine on it. I just forgot.” Then I’d reflect what we know from research, even from the 1990s, is that the more you hop from medication to medication, the less chance of efficacy. But that’s not what I usually see. Usually what [individuals say] is, “I stopped because it worked, and then it stopped working.” It wasn’t simply a change of insurance or that they forgot to take it. I see that there were issues with what they were taking. It could have been adverse effects of any kind, weight gain, the frequency of dosing, sexual dysfunction, anything. That’s usually what I see, and that gives me a reason to help showcase what else is out there.
When individuals come to me, not everybody wants to change meds when they first meet me. They’ll say, “I’m OK.” But as Charles said, that OK might be a 6. I initially painted the picture of, let me tell you what’s out there. It’s no different from my phone. This isn’t the latest iPhone, but I upgraded this 1 because I like the camera. I let patients know from the first day that they’re with me, “That’s great. I’m glad you’re at a 6. But if you want to be at an 8 or a 10, let me tell you what’s out there. It’s still medication for depression, but this is why I like this over that.” I showcase hope. I encourage them to go to the websites and look up the data of hundreds of other individuals just like them. See how they are. Some individuals say, “I want to upgrade my medications just like I upgraded my phone.” For others, it takes a bit. When they go back into this episode, it’s within chronic. When they dip, I’ve already had that discussion. I say, “Here are our options. Let’s try it.” That’s how I treat patients. I’m not here to strong-arm them and say, “You’ve got to change this.” We need to mix it up. That’s not what I do. I present the data and let them pick.
Gus Alva, MD, DFAPA: And you give them options.
Carmen Kosicek, MSN, PMHNP-BC: I’m going to give them options, but I’m not going to give them options of something that’s wrong. I’m going to say, “Here are the [options].” At the same time, it’s not the only option. “[I say] here are the different options. Here’s why I would pick this 1 over that 1. This is my opinion. This is what I do for a living and why I’d go with this. Let me know when you’re ready.” Because if they’re not ready, it’s not going to work.
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