International perspectives: The patient with MDD who does not respond adequately to antidepressants

Unmet need

Dr Sepalo Rose Leputu, Polokwane, South Africa

In Dr Rose Leputu’s experience, more than half the patients she sees in her private practice clinic with MDD won’t respond to first-line antidepressant medication. She said that in general, those who do respond initially to medication, tend to do better in the long-term. By contrast, patients requiring more than one line of anti-depressant medication can take longer to attain remission. In Dr Leputu’s experience, these patients may then reach a point where they no longer have symptoms of depression, but often their level of functionality is poor: patients can have poor concentration levels, forgetfulness and lack of interest in returning to work.

Dr Fagan Zakirov, Istanbul, Turkey

In Dr Zakirov’s experience, 1-2 out of every 10 MDD patients do not respond to antidepressant therapy. Quality of life in such poor responders is decreased and he noted that frequently these patients are unemployed, may be isolated, and that their family and social relationships suffer.

Professor Jorge Forero, Colombia

Professor Forero finds that around 50% of patients respond to the prescribed dose of their first antidepressant therapy – a statistic based on assessments made at 3 months.

Dr Sealanyane Simon Mothapo, Nelspruit, South Africa

Fewer that half of Dr Mothapo’s patients fail to respond to the first antidepressant therapy administered. Dr Mothapo has experienced that in those patients exhibiting a poor response, MDD symptoms may actually worsen following initiation of an ineffective therapy.

Professor Jorge Ospina, Colombia

As Professor Ospina pointed out, it is important before treating a patient with MDD to confirm the diagnosis of depression is correct. Frequently, patients with borderline personality disorders are referred with a diagnosis of depression. He finds that often these patients, and those with symptoms of anxiety, don’t respond well to antidepressant therapies. He said that patients with confirmed MDD who don’t respond to antidepressant therapy initially, often have a greater level of general and social dysfunction and impaired cognition compared with patients who do respond to treatment, and that these features tend to be associated with a poorer overall patient quality of life.

Dr David Chapman, Darwin, Australia

Dr Chapman said that while it is often reported that one in two patients with MDD don’t respond adequately to antidepressant therapy, this is not what he sees in his practice. He pointed out that if the diagnosis of MDD is correct, most patients will respond to antidepressant treatment but that response may be inadequate, and many patients ‘will just live with it’. He said that in his experience, only around one in five patients returns to clinic because therapy isn’t working.

Many patients are referred to Dr Chapman by GPs and he said such patients may have been on antidepressant therapies for years.

Diligence to inadequate responses

Dr Sepalo Rose Leputu, Polokwane, South Africa

Dr Leputu said that typically, signs of a response to antidepressant therapy (seen either by the patient or a family member or carer) should be evident within 2 weeks of initiating therapy. If no response is noted at this point, then Dr Leputu would intervene and try an alternative therapeutic approach. However she said that a ‘wait and see’ approach may be taken by some physicians.

Dr Fagan Zakirov, Istanbul, Turkey

If an antidepressant is having little effect in MDD, Dr Zakirov believes this can usually be confirmed within 1-2 months of starting treatment and believes that, ideally, physicians should act more rapidly than this wherever possible.

Professor Jorge Ospina, Colombia

Professor Ospina said that in his experience, an adequate antidepressant response can be seen after 8 weeks (12 weeks in older patients) but if patients are seen on a more frequent basis, a response may be noted earlier. He thinks that many physicians may delay taking action when an antidepressant therapy fails to work and feels that clearer protocols are needed for evaluating patient responses.

Dr Sealanyane Simon Mothapo, Nelspruit, South Africa

Dr Mothapo would expect to see an initial response to antidepressant therapy within 2 weeks. If he notes there is no initial response, he might consider whether dosing is adequate and then expect to review responses within 8 weeks from commencement of therapy.

Access issues

Professor Jorge Forero, Colombia

Professor Forero said that in Colombia, few patients with MDD have immediate access to therapy and, therefore, treatment is often late in getting started. However, once treatment is started, he has observed that patients can respond well, and in some cases, a combination of pharmacotherapy and psychotherapy (a combination he always uses) may be life-saving.

Goals for patients

All those we interviewed want the best for their patients. As Dr David Chapman of Darwin, Australia noted, function is key – and antidepressant and adjunct therapies should be tailored to the presentation. As he stated, a patient can’t be given CBT if they cannot function.