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MDD Treatment: Follow-Up


Greg Mattingly, MD, and Jeremey Schreiber, MSN, PMHNP-BC, discuss best practices for monitoring and follow-up with patients with major depressive disorder (MDD) to ensure treatment efficacy and safety.

Greg Mattingly, MD: Let’s talk about follow-up. In our chronic [treatment] models, I’ll typically see [a patient] back in maybe 4to 6weeks, unless somebody’s suicidal, unless there’s other things. Typically, we say it’s going to take 4to 6weeks for a medicine to get [a patient] better…. If we have treatment options that are working over the course of a couple of weeks, will that change the way that you see [patients], or will you measure remotely to see how they’re doing? How do you envision that with your practice and the people who work with you?

Jeremy Schreiber, MSN, PMHNP-BC: That’s a good question because in terms of the way we currently do things, it’s often I’ll see [a patient] back in 4 to 6 weeks. That’s [because] it takes about this amount of time to get our patients better. As we change the paradigm and we use some of these more rapid-acting agents, we’re going to be seeing our patients much sooner. For instance, let’s say there’s a course of medication that’s 2 weeks long. I’m going to get that patient back and I’m going to see that patient. If for some reason I don’t have an opening in 2 weeks or something of that nature, I’m still going to want that patient reporting back to me. And then I’m going to see them back probably in a week or 2 after that, as soon as I can get that patient in for follow-up. That allows us to stay on top of the symptomatology that our patients may present with and see how they’re doing. The other thing that that will do, when we talk about the rapid acting of these agents, is…hopefully allow us to get our patients feeling better faster. I think that is of paramount importance because being depressed is no fun. It’s awful. The patients suffer. They’re going to work, but they’re not really working at work, or they’re more likely to get in trouble with their bosses, etc. If we can get our patients better faster, this opens up a different paradigm in terms of our monitoring. We base our monitoring on the efficacy of our agents, for lack of better terms, and if we can get someone better, faster, let’s get them in and let’s be on top of it. The last thing I want to say [here]is when I talk about the change in terms of the frequency with which we will continue to follow up with our patients or may follow up with our patients, this also sets the stage for our patients to have better results. At the same time, it sets the stage for us as providers to be as vigilant as we humanly can be when we’re treating depression. You used the word much earlier talking about being very aggressive with treating depression and getting it controlled. This gives us more ability to monitor, keep track of, follow up, and stay on top of any of these symptoms. We can start to look at depression more as an episodic condition compared [with] a chronic condition, if we can get our patients well faster.

Greg Mattingly, MD: Let’s take a step back. Maybe some of the people in the audience are saying, “Wait. You guys are way out over your skis out there. I work in a clinic, and I see a lot of people, and I’m in a community mental health center, or I’m in rural Missouri or Arkansas or Kentucky. I’m just trying to do the best I can.”Way back when with [the] STAR*D [clinical trial](NCT00021528), 20 years ago, the first treatment there was an SSRI [selective serotonin reuptake inhibitor]. It was the first treatment. What I would say to the audience out there is Maurizio Fava, [MD,] who’s the chair of psychiatry at [Massachusetts General Hospital], just wrote an article in JAMA [The Journal of the American Medical Association] and they said, even with all of our current evidence, what’s probably going to be your first treatment option for the average person who comes in [and] has never tried anything? It’s probably going to be an SSRI. They say that right there in their article, and they go through the data, and most guidelines around the world would say this. The mistake you make is your second treatment and your third treatment is another SSRI….Jeremy, I know you’ll resonate with this, it’d be like if you had an infection. Let’s say you had bronchitis and maybe the doctor said, “Hey, right now, amoxicillin is the best treatment for this version of bronchitis.” And you came back, and the amoxicillin wasn’t doing the job. And then he said, “Hey, we got a really good antibiotic. I’m going to give you penicillin.” What would you say if the guy just kept pulling another -cillin after another -cillin?

Jeremy Schreiber, MSN, PMHNP-BC: I would probably ask for cephalosporin or something;give me something different or do some combination therapy.

Greg Mattingly, MD: How about this medicine called cipro [ciprofloxacin]? I’ve heard about that. Or how about Augmentin [amoxicillin/clavulanate potassium] or whatever? The mistake we make is we’re used to those tools, we’re used to our habits, and we just repeat the same mistake. There’s a good first-line treatment option. The question is, how do you individualize it after that first-line treatment? I never want to put shame on people for using SSRIs in our standard state-of-the-art [treatments]. They’re there for a reason. But the question is, what do you do next? Here’s my new term when I think of people who have recurrent depression, smoldering depression, or untreated depression. [Those are] all versions of the same thing. You’re living with depression, and either your treatment isn’t working or you’re not getting the right treatment. That depression is metastasizing in your life. It’s metastasizing and spreading in your life. It’s damaging nervous system pathways. It’s damaging neural connectivity. It’s damaging your life from a productivity standpoint when it comes to functioning at your job or at school or in your marriage. It’s damaging your life in your relationships. One of the big [takeaways] for me, and I’ll get your impact, [from] STAR*D [was about]…people who struggled with depression [after] a year [of treatment], if they hadn’t gotten better. One of the most striking things to me, and I got a tear when I first read it, was the impact on a mom and how it impacts her kids. If a mom with depression isn’t better by the end of the year, isn’t all the way better? Her kids are doing less well in school. They’re having a harder time making friends. They’re doing less well academically; they’re doing less well emotionally. It spreads within your life when you’re struggling with depression if you’re not getting appropriate treatment.

Jeremy Schreiber, MSN, PMHNP-BC: Yeah. When you look at the research in terms of postpartum depression, when you talk about mothers suffering, and you look at infants who are born to mothers who are suffering with postpartum [depression], you’re looking at reduced maternal-infant bonding, which isn’t good, but that’s not the only problem. The development of these infants becomes affected across their lifespan. It’s not just little Timmy can’t stack 2blocks or 3blocks or make a bridge when he should make a bridge, but by the time he [is]18 or 22 or 26 or 45, he’s as good as he’s going to be. It’s not that way. You look at developmental impact for these infants over the course of their lives. That’s what the research shows. When we think about maternal depression, we also need to think [about how], like you said, it metastasizes into the family. It’s not just that infant, but it’s also the whole family. Maybe it’s school-aged children, maybe it’s the husband. When you look at divorced people with depression, there’s a 200% increase in the [number] of people who become divorced if they also have depression. It’s a huge factor for relationships at home.


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