How Advanced Practice Providers can Tailor Individual Depression Treatment

Advanced practice providers working in mental health care can anticipate that depression diagnosis and treatment will be a frequent feature over the course of their careers. How can APPs choose the best antidepressant for their patient, and how should they proceed if initial treatment doesn't work?

On Saturday, April 29th, at the inaugural NP Institute meeting held in Boston, Andrew Penn, MS, PMHNP, associate clinical professor, psychiatric clinical nurse specialist, University of California, San Francisco, presented his session “How to Choose the Right Antidepressant for Your Patient” before an audience of psychiatry nurse practitioners, physicians, and other mental health care professionals.

Ahead of his presentation, Psych Congress Network connected with Penn to explain some of his key clinical pearls for APPs regarding antidepressant options, tackling non-response, and working to tailor treatment to patients’ goals.

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Brionna Mendoza, Associate Digital Editor, Psych Congress Network: What are a couple of key factors advanced practice providers (APPs) should keep in mind when choosing an antidepressant for their patient?

Andrew Penn, MS, PMHNP: First of all, there’s no need to reinvent the wheel - if someone has been on a medication that worked in the past for similar symptoms, use that one again. 

Second, antidepressants have largely similar effects when you look at them across groups. However, in an individual, there will likely be one antidepressant that works better than others. Our job is to figure out which one that is. 

Third, make side effects your ally. Mirtazapine, for example, makes people sleepy shortly after taking it, so it’s very useful for a patient with depression who has insomnia. On the opposite side of the spectrum, bupropion is quite activating, so it can be a useful side effect for a patient who is struggling with low energy and fatigue.

Mendoza, PCN: What next step would you first recommend for APPs treating patients who don’t respond to initial treatment?

Penn: First, make sure the patient is actually taking the medication on a regular basis. Then, consider switching to a different class of antidepressant. Finally, don’t wait until you’ve tried 7 or 8 medications before considering a procedural treatment like transcranial magnetic stimulation (TMS) or ketamine infusions. 

Mendoza, PCN: What advice would you give to yourself at the beginning of your career as an NP on the topic of prescribing antidepressants?

Penn: It’s going to be okay—you’ll get there with your patient if you keep trying.

Mendoza, PCN: How might clinicians more effectively proceed if their patient is initially resistant to taking medication for their depression?

Penn: Taking medication is a big decision, and we need to respect that. Try to align how the patient’s goals might align with the effects of the medication. One of my teachers once said that he asks the patient, “If this medication were to work, what would it allow you to do that you can’t currently do today?” Framing in this manner brings in the element of hope (and helps us to understand how depression has really impacted their lives). 

Andrew Penn, MS, PMHNP, was trained as an adult nurse practitioner and psychiatric clinical nurse specialist at the University of California, San Francisco. He is board certified as an adult nurse practitioner and psychiatric nurse practitioner by the American Nurses Credentialing Center. He has completed extensive training in Psychedelic Assisted Psychotherapy at the California Institute for Integral Studies and has published in the American Journal of Nursing, Bipolar Disorders, and Frontiers in Psychiatry. He was a study therapist on the MAPS-sponsored Phase 3 study of MDMA assisted psychotherapy for PTSD and is currently a co-investigator on the Usona-sponsored phase 2 study of psilocybin facilitated therapy or major depression.

Currently, he serves as an Associate Clinical Professor at the University of California-San Francisco School of Nursing where he teaches psychopharmacology and is an Attending Nurse Practitioner at the San Francisco Veterans Administration with the joint UCSF/SFVA NP residency program. He has expertise in psychopharmacological treatment for adult patients and specializes in the treatment of affective disorders and PTSD. He has published on the risks and benefits of cannabinoids in psychiatric treatment.

As a steering committee member for Psych Congress, he has been invited to present internationally on improving medication adherence, cannabis pharmacology, psychedelic assisted psychotherapy, grief psychotherapy, treatment-resistant depression, diagnosis and treatment of bipolar disorder, and the art and science of psychopharmacologic practice. In 2021, he was awarded the Distinction in Teaching Award by the UCSF Academic Senate.