Improving Remission Rates in Patients With Major Depressive Disorder

Orlando, FL—Approximately 9.5% of the US population suffers from depressive disorders. It is expected that by 2020, depression will be the leading cause of disability worldwide. Moreover, the average age of onset is getting younger. Fifty years ago, the average age was 29, now it is 14.5.

Major depressive disorder (MDD) is not only extremely prevalent in the United States, it is costly as well. In 2000, the total cost of MDD was $83.1 billion, which included workplace costs, suicide- related costs, and direct medical costs.

Depression is often difficult to treat, but there are strategies to improve the possibility of remission. These strategies and the overall impact of MDD were discussed during a session at NAMCP.

The session, led by Mark Rosenberg, president, BHM Healthcare So- lutions, focused on treatment strategies for patients with treatment-resistant depression, as well as ways to improve outcomes.

There are a variety of treatment op- tions that may help improve patient outcomes, including pharmacologic options, psychotherapy strategies, medical devices, and alternative therapies. Some of the current pharmacologic options are serotonin norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants, monoamine oxidase inhibitors, and adjunct therapies such as mood stabilizers or anxiolytics.

Although many treatment options are available, Mr Rosenberg said up to 70% of depressed patients respond to treatment, but do not achieve remission from their emotional and physical symptoms; only about 30% of patients are able to achieve remission after receiving treatment.

There are certain factors that have been shown to improve patient outcomes. One large, multisite study showed that patient preference often plays a key role in outcomes. According to the study, patients had better outcomes if they were assigned to a treatment option that they would have preferred themselves.

Other studies have found that people with low levels of cardiovascular fitness have a higher incidence of depression and those who eat a diet rich in processed foods are also at an increased risk for depressive symptoms.

For patients in the acute phase, Mr Rosenberg suggested physicians begin by choosing an initial treatment that is designed to achieve remission from major depressive episodes and return the patient to baseline functions. When developing a treatment plan, it is important to consider the patient’s preference and the individual clinical features of each patient.

Antidepressants are typically recommended in early treatment for patients with mild-to-moderate depression and are essential for those with more severe forms of the illness. According to Mr Rosenberg, since the available medications within a given class are often comparable to one another, factors such as side effects, cost, or patient preference may drive the drug decision. If a patient experiences side effects, he said the first step should be to decrease the dose or change the medication rather than stop medicating altogether.

To determine the effectiveness of treatment, Mr Rosenberg said it is important to make certain that treatment has been administered long enough, typically about 4 to 8 weeks, before an accurate evaluation can be made.

Sometimes physicians may need to alter their treatment plans and Mr Rosenberg highlighted several ways to do that. For instance, in antidepressant treatment, it may help to optimize the dose if the drug is well-tolerated and the upper limit has not been reached. Or providers may consider adding depression-focused psychotherapy, changing medications, or using electroconvulsive therapy. Other strategies include adding an atypical antipsychotic anticonvulsant, omega-3 fatty acids, folate, or psychostimulant medication. For those prone to anxiety or insomnia, adding anxiolytic and sedative hypnotic medications may help.

Patients with ≥3 prior depressive epi- sodes or those with chronic MDD are good candidates for a maintenance phase of treatment, according to Mr Rosenberg. During this phase, antidepressant medications that helped achieve symptom remission should be continued at full-dose and therapy may continue with slightly less frequency.

Between 10% and 30% of depressed patients on antidepressant medications are either partially or completely resistant to treatment. Some of the reasons for treatment resistance may be undiagnosed medical conditions or comorbid conditions, use of certain nonpsychiatric drugs, or poor compliance.

Strategies for Treatment-Resistant Depression

Mr Rosenberg offered several strategies to treat patients with treatment-resistant depression. One of these strategies is optimizing the dose of antidepressant medications for those taking a low dose of a medication or those who have not been on the medication long enough. Another option is substitution, particularly switching from one antidepressant to another drug with a different mechanism of action, which has been found to produce good results.

Adding a second antidepressant agent to therapy or augmenting therapy by adding a second agent not routinely prescribed for depression may also be a beneficial option for these patients. According to Mr Rosenberg, the advantages of combination or augmentation strategies is that they can build on thera- peutic gains, may lead to a more rapid onset of antidepressant effects, and are typically well-tolerated; however, they can also increase potential drug interactions, reduce compliance, and increase adverse effects.

Mr Rosenberg concluded the session by offering tips on how to improve patient outcomes. He said noncompliance is often a common problem, with 75% of antidepressants discontinued by the fourth month.

Providers need to educate patients upfront about the disease, treatment options, and common side effects they may experience. Mr Rosenberg said it is important to stress why the medications need to be taken on a daily basis and to assure patients they are not ad- dictive. Discussing the mind and body connection with patients and encouraging behavior modification tactics, such as exercise, eating healthier, attending support groups, talking with family, and getting enough sleep, can also be beneficial.—Jill Sederstrom