Treatment Selection for MDD

Drs Andrew J. Cutler, Gregory Mattingly, and Sagar V. Parikh share their approach to treatment selection for patients with MDD.

Andrew J. Cutler, MD: Now, let’s talk about the treatment landscape for MDD. Greg, can you talk a little bit about how a clinician thinks about selecting a treatment? What are some of the criteria that they might use in thinking about which medication to choose since we do have a bunch of options right now?

Gregory Mattingly, MD: At this point, we have dozens of treatment options when it comes to depression. I think many of us start by taking our patients histories. Walk me through your symptoms. How often do symptoms come about? How do your symptoms run together? Do you have anxiety? Do you have insomnia? Do you have decreased energy? Do you have agitation and irritability? So, I think we take a symptom-based approach as something we’ve all learned to do, Andy. Beyond that, I think we look for what’s worked in the past. What are the medicines that have been helpful for your depression? What medicines have not been helpful? Be that a selective serotonin reuptake inhibitor [SSRI] with high efficacy or an SSRI with unwanted adverse effects. We then move beyond symptoms, beyond treatment response to probably try to think about what are some of the long-term goals of treatment. I think about the comorbid conditions they may have at this stage in their life. Do they have things like hypertension where I want to avoid an agent, maybe a serotonin-norepinephrine reuptake inhibitor [SNRI] that has a risk of increasing blood pressure? Are you an older person who’s maybe starting to have some sexual difficulties as part of where you are at this stage of your life? I want to minimize medicines that may have sexual adverse effects. We know that for many of our women, the bane of existence that they don’t want is weight gain. So, trying to minimize weight gain for some of my female patients. Andy, when I sit back, I’ll start with once again, that developmental history. Tell me your symptoms. What do you tend to get stuck with when you’re having depression? Let’s walk through what’s worked in the past, and what hasn’t worked in the past, but then let’s think about those in terms of your current physical and emotional well-being and what adverse effects we want to try to avoid.

Andrew J. Cutler, MD: I think that’s really well said. One thing I might add is that I sometimes ask about family history. If there’s someone in the family who’s responded well to a particular antidepressant, well genetically, maybe that’s a likely place to start. Sagar, how about this idea about symptom complexes and various symptoms and how that might drive my choice of which medicine I might use? You mentioned that this is a heterogeneous illness previously.

Sagar V. Parikh, MD, FRCPC: I think I start at a slightly different place. I know that the patient is in it for the long haul so I want to spend a little bit more time upfront getting inside their head, understanding their model of illness, and getting a sense of their motivation. I spend more time, in the beginning, talking about depression and providing information about it, and then checking with the person like, what do you want to hear more about? There’s a natural resistance to medications and that’s fine. Many nonmedication treatments work for depression. If we’re going to have a good therapeutic alliance, I want to first meet the person where they’re at, answer their questions, and if they happen to be nonmedication questions, I’d like to pursue that and get a sense of where they’re coming from and then I’m going to circle back to symptom clusters and medication choices and things like that. I think first try to figure out what makes the patient tick, and what is acceptable to them in terms of a model for depression because we’re hearing all kinds of fake news about serotonins not involved in depression and various things like that. Rather than just run a rough shot over any sort of lingering doubt in the patients mind, what have you heard about depression? I think you do have a very treatable medical disorder. It has many treatments. Some are psychotherapy, some are medications, and there are other things. Were you already thinking about something? Or is there a family member who’s had a treatment? I’d like to first try and engage them and get a sense of where they want to go to decide how to present the information. What I found is that when you present it that way, inevitably they will circle back to the more traditional treatments because they trust you. They don’t necessarily want to immediately take the pill but once you’ve satisfied their curiosity about psychotherapy or exercise or yoga or something then they’re more receptive to, “Well, by the way, could you tell me a little bit more about medication?”

Gregory Mattingly, MD: Sagar, I think you said something just incredibly important for our audience. Get to know your patients as people first. My interview always starts with, “Where are you from? Where did you grow up? What did you like to do when you were a kid? Go back in time. What were the fun things? What were the good things?” I always start with strengths, not weaknesses. Then do this developmental history where I’m walking through their life as I’m getting to know them, but I’m looking for the root of where things started to happen. Where did we first start to pick up anxiety or depression or emotional changes, or maybe childhood trauma? But I’m getting to know my patient. I think you’re right. Before you talk about treatment options, they’re not there just to have a symptom checklist for depression. They’re there to be treated holistically as people.

Transcript edited for clarity

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