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“The real challenge in treating MDD is choosing the right option first time,” said Dr Virginia Soria, Spain, “and making sure that the balance between effect and tolerability works right from the start of therapy.” As she explains, in this way benefit can be gained from the outset and long-term issues such as the worsening or persistence of symptoms can be avoided.
In her experience, the best approach is to treat intensively. Therapies should be tailored to take into the account the severity of the patient’s depression, their age and the type of symptoms being experienced. Achieving a partial response or the persistence of residual symptoms is not the end-point of the treatment, especially in certain subgroups of MDD such as melancholic depression. “We have to get the most out of therapy as early as we can,” she said. And to do this establishing a relationship of trust with the patient is essential. This involves the patient being empowered in the management of the condition and to be a willing participant in their treatment programme.
Dr Soria defines remission in MDD when there are few or no mood symptoms present in a patient as measured using a suitable rating scale. However, while remission is desired, recovery is her ultimate goal – that is a complete, sustained remission with functional restoration in the patient. She estimates that 30-40% of patients attain remission at the first attempt. In those that do not initially remit, further interventions are employed including use of combinations of therapies, augmentation and neuromodulation. Use of ECT can lead to attainment of remission in 70% of those in which it is being used. “Don’t stop treatment after the first attempt,” she said, “If a patient is resistant to antidepressant therapy, re-evaluate them with an open mind and look for the treatment regimen that better suits them.”
Dr Soria believes in the use of a more holistic approach to the management of MDD as it has been reliably demonstrated that psychopharmacology and psychotherapy in combination is more effective in gaining symptom remission than either therapy used alone. Ideally, combination therapy should be used from the outset of treatment. This also includes offering advice on lifestyle management including diet and exercise. “It can often take longer to persuade a patient to exercise than to take their medicine!” she reported.
Currently, Dr Soria evaluates cognitive symptoms in depression mainly in her elderly patients using the Mini-mental state examination or MoCA Montreal scales but, as cognitive symptoms affect global performance and functionality regardless of age, she plans to pay more attention to the assessment of these in future in all patients with depression.
Interview with Dr Virginia Soria, Barcelona
Curiously, not responding at all to pharmacological therapy may sometimes be better for a patient than a partial response, since lack of response forces a change in treatment.
With a partial response, both we and the patient may settle for second-best: a compromise outcome that leaves quality of life and functioning impaired. Perhaps the patient does not complain so much. They may be greatly improved on the standard assessments we apply. Symptoms are not as intense. But if we talk to them with time and attention we can see they are still not satisfied.
They are not as engaged with life as they used to be, and lack motivation and interest. They cannot plan long-term or make decisions. It is like walking through water, or driving a car with the brakes on. Perhaps they have other difficulties, such as anxiety. Though not a core symptom, anxiety is prevalent in depression and can be disabling since it is a great barrier to action and cause of insomnia.
This is surviving, not living. We have treatments that permit the next step. Yet we are perhaps reluctant to change the treatment for fear that what has been gained may be lost. The key, in my opinion, is to augment therapy rather than switch it again.
At this stage, there are several options. Prof Fagiolini stated that thyroid hormones are often not very effective and have side effects, with the risk of atrial fibrillation and osteoporosis. Lithium is a possibility but again there are side effects such as thyroid dysfunction, tremor and nausea. Another option is to add an antipsychotic. A depressed patient may not like the idea because they don’t have psychosis. But this is just a question of nomenclature, not efficacy.
We know that newer antipsychotics, which work on many different receptors and not just dopamine, can also be good as adjunctive treatment to antidepressants. Mechanism of action can be explained to the patient. Each of these agents has different side effects, and choice needs to be tailored to the circumstances of the individual patient. Some will appreciate a sedating action as a side effect, but others not. It is about striking the right balance.
An interview with Andrea Fagiolini, Associate Professor of Psychiatry at the University of Siena School of Medicine, Italy