Identifying “State of the Art Treatment” for MDD
Is there one state-of-the-art treatment for depression? “No, that was the dilemma I faced in trying to prepare for this talk, ” Sidney Zisook, MD, shared with attendees of the 2022 Annual Psychiatric Times ™ World CME Meeting held in August in San Diego, California.
“There is no state-of-the-art treatment because major depressive disorder [MDD] is such a broad, diverse, heterogeneous group of symptoms, ” explained Zisook, who is distinguished professor at the University of Ca, San Diego, and a previous recipient of the particular Psychiatric Occasions ™ Educator associated with the Year Award. “In fact, there are 227 possible combinations of symptoms that will allow a person to meet the DSM criteria for [MDD]. And, in addition to the symptomatic heterogeneity, there are a host associated with other issues that affect this: severity—mild symptoms versus very severe problems; clinical features—are there anxious features, atypical functions, or melancholic features? All of these may lead us to different approaches that we may take with that patient. ”
Because of this, there are a number regarding issues and features that should be assessed for each individual. Zisook discussed a recent review that will revealed 14 key areas: symptom profile, clinical subtypes, severity, neurocognition, functioning plus quality of life, medical staging, personality traits, antecedent and concomitant psychiatric conditions, physical comorbidities, family history, early and recent environmental exposures, protective factors, resilience, in addition to dysfunctional cognitive schema. 1
Thus, the particular best care practice—which is really what makes for state-of-the-art treatment with regard to MDD—relies on a thorough history, Zisook said. “A really thorough history begins with lab studies, physical exam, etc, ” he said. “But the initial assessment is not enough. We want to repeat the workup for patients who aren’t doing well over time. ”
“I can’t tell you how many times in my career, when I redid my preliminary assessment 6 months down typically the line and even somebody wasn’t having the good response, how different that history was together with how I now—for the first time—learned about their drinking history and the cocktails they had every night. Or their early life trauma that was very much affecting their own day-to-day existence as an adult, and so on. So not only do you do good assessment to begin with, repeat it intermittently as you have a better relationship with the patient to get a better, fuller picture involving who they are, ” Zisook said.
This includes checking regarding cooccurring problems and ensuring treatment intended for those circumstances, too, said he explained.
Similarly, this individual said it is important to use measurement-based care to inform decisions. “Several studies 2 have found that if you measure symptoms, in case you determine side effects, even with a new global side effect measure along the way, share those with the patients, and develop a diary connected with symptoms and additionally tolerance, you’ll actually end up with better results, ” Zisook reported.
Then, clinicians should dip into the wide variety of choices from what he or she called this “2022 Antidepressant Tool Kit. ” In terms with medication choices, Zisook told attendeed all FDA-approved antidepressants (ie, tricyclics, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, serotonin modulators, and atypical antidepressants, not to mention novel nonmonoamines) are equally effective along with some differing adverse effects.
When discussing medication treatment personalization, often the topic for pharmacogenomic testing often comes up, stated Zisook. “There was a lot of excitement regarding pharmacogenetic testing a few years ago. A lot of which excitement has died down because it hasn’t really proven to have a dramatic impact upon our ability to personalize medications, ” he informed attendees.
However , testing can provide information about the genes involved in the metabolism of medicine (eg, CYP2D6, 2C19, 1A2, 2C9, 342, and 2B6), how the drug may be metabolized in individuals, and whether the medications should be used as usual, together with caution, or with extra caution and also increased monitoring. “If they [patients] are a very poor metabolizer, these people may end up getting a very high dose from the medication that you’re providing in their system, and they will might be more prone to significant side effects adversity and tolerance, etc . You may need to go slower or even lower or perhaps avoid certain medications, ” he advised attendees.
Brain stimulation options (ie, bright light therapy, electroconvulsive therapy, transcranial magnetic stimulation , as well as vagus nerve stimulation) are also effective strategies in your tool kit, he noted.
Furthermore, Zisook reminded conference attendees not really to overlook the potential about psychotherapy as part of the treatment strategy.
“A current survey showed only concerning 20% in psychiatrists carry out psychotherapy within their offices, even though we all know the fact that psychotherapy plus meds will be better than meds alone. ” 3
Lifestyle aids, like exercise, will also be important and should be considered included in the treatment plan, he mentioned. “I tell all my individuals, ‘When you are feeling more energetic, whenever you’re up to this, start exercising. Get out of the house, take advantage the sunlight. ’ They may not necessarily be able to do that initially. But I plant the seed early on and go back to the idea. ”
The therapeutic alliance is key in order to success, Zisook said, plus sometimes may be overlooked. He shared results through a National Institute from Mental Health study that found psychiatrists can “augment the effects” of both the medicines as nicely as placebo. 4 “Those sufferers who had the best results actually with placebo were the ones that maximized the exact nontherapeutic, nonspecific factors that are common to be able to psychotherapy that’s effective, like developing some sort of therapeutic alliance: getting a trustful, empathetic, in addition to collaborative relationship with a patient, ” they said.
“Take advantage of those factors—and yourself, ” Zisook advised. “This may mean spending more than 20 minutes with a patient. It may mean seeing their family. It might mean talking about their particular life independent of their very own depressive symptoms. But that will relationship is usually critical in helping many of our people get better. ”
Zisook concluded by reminding meeting attendees associated with their network of support and the importance of engaging colleagues because needed.
“Never worry alone, ” he / she said. “It’s always so nice any time you’re treating people with depression—especially difficult to treat depression—to have a colleague, other people that you can work with, you can consult using, to talk about sufferers. And I’ve always found that a critical part of the overall practice. ”
1 . Maj M, Stein DJ, Parker G, et al. The particular clinical characterization of the adult patient having depression aimed at personalization of management. World Psychiatry . 2020; 19(3): 269-293.
2. Rush AJ, Sackeim HA, Conway CR, ainsi que al. Clinical research challenges posed simply by difficult-to-treat depression. Psychol Med . 2022; 52(3): 419-432.
3. Zisook S. 8 key problems in the particular world regarding major depressive disorder. Psychiatric Times . 2022; 39(7): 21-23.
4. McKay KM, Imel ZE, Wampold BE. Psychiatrist effects in the psychopharmacological treatment involving depression. J Affect Disord . 2006; 92(2-3): 287-290.