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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
Dr Kane spoke on current treatment options at a satellite symposium on functioning and quality of life (QoL) as long-term treatment goals in schizophrenia. Afterwards, our correspondent spoke with him to hear more of his views on current treatments and patient outcomes.
Psychiatrists need to increase their focus on these important aspects of the disease. Until now, their attention has mainly been directed towards managing the key signs and symptoms of schizophrenia. However, for patients and their families, a good QoL, functioning and leading a normal life are extremely important. By ‘normal life’ I mean patients being engaged in the community, having relationships, and being able to go to work or school – patients need help in achieving these goals. They need to be taking the best medicine for them, to be helped to continue taking it, and to be offered psychosocial interventions to support them in this process.
The things that are most important to patients are social relationships, having a job, a place to live, an intimate relationship, and hobbies. Like any person, patients want to feel connected to others, that they belong in their families and communities, and that they are living their life in a meaningful way – this is what anyone would want.
Outcomes currently leave a lot to be desired. Only about 14% of patients with schizophrenia achieve what we would call a recovery and are able to achieve all the sorts of goals we have been talking about above. A primary driver for the clinician is to address the symptoms that first brought the patient into the healthcare system, for example, agitation and aggression. These are obviously symptoms to manage, but treatment strategies for these acute problems are not necessarily the most useful for long-term overall management of the patient’s condition. Moreover, in the community patients are often not getting all the help they need to improve their functioning and QoL. Physicians are trained to help solve medical problems, but they also need to work with colleagues to ensure that their patients get access to and benefit from psychosocial interventions. These are often needed to help manage the patient’s physical health and well being, their lifestyle, avoid substance abuse, stop smoking etc. Otherwise schizophrenia takes a large toll on patients: chronic and severe mental health issues can reduce a patient’s life expectancy by 15 years.
The importance of medication in managing schizophrenia has been demonstrated beyond doubt. However, understandably, people do have problems taking oral medication in the long-term. So long-acting drugs offer the option for patients to receive their treatment at less frequent intervals, which also allows us to maintain contact with the patient, and undertake other psychosocial interventions over a long period of time.
Use it, use it and use it! These drugs are currently under-utilised. So work with patients; spend the time to understand why they may be reluctant to try these treatments, and work out how to present this treatment option to the patient in a way that will appeal to them. Working with patients in using LAIs is a process that takes time, so don’t give up too quickly. If the psychiatrist and the patient work together within a good therapeutic alliance, they can both take steps to prevent relapses and optimise the patient’s long-term outcomes.
An interview with Dr John M. Kane, The Zucker Hillside Hospital, Glen Oaks, New York, USA.