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Early optimized therapy enhances full functional recovery in depression

Dr Joslyn Ngu
30 Nov 2017

According to a review, using a patient-centred approach to provide early and optimal pharmacotherapy in major depressive disorder is more likely to result in full functional recovery. [Int J Neuropsychopharmacol 2017; Doi:10.1093/ijnp/pyx081. Epub ahead of print]

When forming a treatment plan for major depressive disorder, clinicians need to take into consideration three crucial factors: individual patient characteristics such as predominant symptoms, medical history and co-morbidities; patient preferences and expectations; and patient’s own definition of wellness.

Screening and early diagnosis is the first step for optimizing treatment. Screening should be done for adults with risk factors for depression and not for all adults in general. Initial screening for major depressive disorder can be as simple as asking two questions and moving on to a validated assessment test if the patient’s answer is affirmative for the two questions. [NICE. Available at https://www.nice.org.uk/guidance/cg90/resources/depression-in-adults-recognition-and-management-975742636741]

Diagnosis can be established using validated assessment tools that incorporate major depressive disorder diagnostic criteria, such as the Patient Health Questionnaire-9 (PHQ-9). For a definitive diagnosis, the use of any assessment tools should always be coupled with a clinician’s good judgement, a psychiatric interview, and additional assessments to rule out other disorders.

Once diagnosed, an individualized management plan should be developed. The authors noted that a key concept to achieve sustained full functional recovery in major depressive disorder is ‘treating-to-target,’ which means to identify specific treatment goals and finding the best way to accomplish those goals. Equally important is to examine a patient’s concept of wellness as it may be different from a clinician’s.

When selecting an antidepressant for the patient, individual patient’s signs and symptoms, medical history and treatment preferences should be considered. Older studies have shown that a wide range of factors such as age, gender, severity of disorder, predominant symptoms and comorbidities are associated with drug efficacy and tolerability.

Monitoring is needed for early improvements in symptoms and functioning, particularly between 1 and 4 weeks after starting treatment. The authors recommended two validated scales for baseline assessments of depression and functional impairment: PHQ-9 and Sheehan Disability Scale (SDS). These two scales can be used on a weekly basis to examine changes in symptoms and function during therapy.  Monitoring results can be useful for predicting later remission or recovery. According to the review, monitoring results in the first or second week of therapy can help clinicians decide regarding dose adjustments. If there is no improvement after a dose adjustment or patient cannot tolerate the higher dose, changing to a different antidepressant or adding an adjunctive treatment can be considered.

It is crucial to monitor for adherence to antidepressant therapy. This is because there are multiple stumbling blocks to adherence. Examples include poor tolerability, social stigma, inadequate patient education, lack of patient motivation, concerns about medication cost, weight gain, sexual dysfunction, delayed onset of efficacy, failure of patients to perceive benefits of treatment and premature discontinuation of treatment after symptoms have improved. Electronic monitoring, pill counts, medication diaries, patient self-reporting, chart reviews, prescription renewal, and pharmacy records are some of the recommended ways to monitor patient adherence to treatment.

Additionally, the review addressed the topic of comorbidities in depression. The authors wrote that comorbidities—psychiatric or general medical—increases the risk of depression recurrence. As such, they suggest that long-term treatment plans which also address the comorbid condition as well as depression should be established for this group of patients.

Delayed treatment of major depressive disorder has been linked to continuous damage to the brain. Fortunately, pharmacotherapy may be able to stop and reverse the damage. Thus, early optimal treatment is key to full recovery, the authors noted.

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