Expert Perspectives on the Unmet Needs in the Management of Major Depressive Disorder - Episode 4
Charles Montano, MD, and Carmen Kosicek, MSN, PMHNP-BC, provide advice regarding monitoring for adverse events and compliance with different classes of MDD treatment and review suggestions for follow-up and special patient populations.
Gus Alva, MD, DFAPA: What do you consider some of the best monitoring recommendations for major depressive disorder (MDD)? What advice would you give someone regarding monitoring? Not just [adherence], because if someone doesn’t take something, it’s not going to work, but also the [adverse] effect profile. We sometimes lose that situation and it’s important, particularly with different patient subsets. Charles, please.
Charles Montano, MD: There are 2 different questions. I’ll take the last one first. And that’s an [adverse] effect profile. If you have an [adverse] effect profile from the most commonly used SSRIs [selective serotonin reuptake inhibitors] or SNRIs [serotonin and norepinephrine reuptake inhibitors], for most of them, not all, [it] includes sexual dysfunction, cognitive delay, and emotional blunting––which is something we must at look more that people have and…know they have it––[and] they will stop taking the drugs for any one of those things. If it’s emotional blunting, they think, “I should be reacting to someone who has died in my family and I’m not; I have nothing, I’m blank.” Then there’s the sexual dysfunction––who wants that? That can be problematic and it can be problematic in relationships, which can make things worse. We need to be monitoring [adverse] effects, but we also need to be monitoring and giving the treatment for the period of time that’s necessary. As you said, 50% of the time it’s a chronic, recurrent episodic problem. I had a gentleman the other day come in after his first serious episode of depression. I [had] treated him for a year and he was on an augmentation strategy in addition to the usual SSRI. He got better, but then his wife got severely depressed, there was more family stress, his daughter got depressed, and he went into another severe depression that wouldn’t respond to a mono immune reuptake drug. I ended up having to augment again, and I told him, “Look, the first time it was 50/50; this time, I think you’re on it probably for the rest of your life. But we’ve got to monitor [adverse] effects and make sure that it’s the right drug for you.” These are the things that we need to think about when we’re treating [patients]. We can’t just treat and forget. And my staff, I remind them every day, if I haven’t seen that patient in 3 months, PHQ-9 [Patient Health Questionnaire-9]––make sure they get one. There are others as well, but that’s the one I used. It’s industry [and] probably that’s the one that you see more than anything else as well. We need to have a high index of suspicion that this disease is not going out, that it’s going to recur [and] the flames will rise again.
Gus Alva, MD, DFAPA: With that said, Carmen, maybe you might apply [your thoughts] on this. First, Charles touched base on the level and frequency of patient follow-up to monitor not just [adverse] effects, but also treatment response. We want to make sure that people are thriving, but there’s also special considerations of different individuals. We know that based on [data from] the different studies that have been done on MDD, we see more females represented than males; two-thirds vs the usual 50/50 spread that you would expect to see based on the fact that both genders are affected by this condition, but most oftentimes females are more likely to seek out help. There is a consideration that someone who’s young and fertile might be thinking about starting a family, and there are specific considerations there. I know I’m asking you 2 different things here, Carmen, but first, talk to us about your suggestions regarding the follow-up for individuals, and whether that should be changing right now, and also specific patient populations, female fertile patients maybe.
Carmen Kosicek, MSN, PMHNP-BC: I agree with Charles that we need to do scale testings for as much of an objective measurement that we can have in psychiatry. I agree on PHQ-9 and GAD-7 [General Anxiety Disorder-7 assessment], and I would also add in an RMS, a rapid mood screener, so that we know what kind of depression is more likely that we’re dealing with. There's a lot of great new technology in under an hour that the patient on their phone or tablet at home can do [regarding] neurocognitive testing. It’s not full-blown neuropsychiatry, but it’s a lot of the same scales. That is something that I have in my practice, but it’s psychiatry, so it might be something that you see in the specialties. Even though the implementation of scales should be done more frequently, I don’t see that it is, and often it’s because our EHR [electronic health record] systems do not have all of those in them. GAD-7 and PHQ-9 are common, but it’s important for the providers to push for the implementation of either MDQ [Mood Disorder Questionnaire]. I like the RMS because it’s quicker to ask to have that added because that is something that can be added to the template. Like Charles said, have the MAs do that as part of the assessment. By the way, it is billable; it’s all about billable, but for more reasons for big systems to make sure that those are done.
When I look at someone of childbearing age, whether they say they are or aren’t planning a family doesn’t matter because we know most pregnancies are not planned. What I’ll look at first, and this is a bit old school, I don’t even know if you remember this reference, [is] the PDR, the Physician’s Desk Reference that we used before. I look for medications that have been well studied, that you can see if there’s VAERS [Vaccine Adverse Event Reporting System] reporting on them because they no longer have categories for medications for pregnancy risk. I look at molecules that have been out for a long time if I know for sure that they’re trying to have a successful pregnancy. …Other things I also look at more holistically. It’s controversial because in health care we like to think that it’s all about pharmaceutical agents, which it’s not. I do look at vitamin D; remember, you need to have calcium there for the vitamin D to be absorbed. I’ll also look for signs and symptoms of MTHFR [methylenetetrahydrofolate reductase] deficiency. You can gauge that through [asking], “Are you a cheap date? How many drinks does it take for you?” or “How many Motrins, Aleves, or Tylenols does it take?” I like to look at those components especially for someone who is stating that they’re trying to obtain a positive pregnancy. From there, how often do you need to see them? With the newer treatments that are out there, please increase your frequencies. As we know in clinical trials, [with] just the engagement alone, you always see a great placebo response, and it’s from the engagement. So especially if you have a couple or individual planning a pregnancy, increase the frequency of those visits; instead of 4 or 6 weeks out, have them come back at 2 weeks, but definitely increase it. With the newer medications that are on the market, it’s good for you as a provider to be able to see the response of what is showcasing in the data, so that you can see that firsthand and realize why it’s important to be progressive in your prescribing. The outcomes are there.
Gus Alva, MD, DFAPA: I love that you introduce the concept of rapid-acting antidepressants, and that within the field we continue to evolve. I’m also particularly happy that you made mention that beyond the pharmacological approach, lifestyle interventions are key and critical. Charles, you touched base on some of the common themes that you often look at with individuals, [including] diet, exercise, physical mental activity, and appropriate hydration…. You also touched base on other treatment modalities, [such as] rTMS [repetitive transcranial magnetic stimulation], vagal nerve simulation, et cetera. We certainly note that there’s a lot of additional things.
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