Announcer:
You’re listening to Clinician’s Roundtable on ReachMD, and this episode is sponsored by Abbvie US Medical Affairs. Here’s your host, Dr. Charles Turck.
Dr. Turck:
This is Clinician’s Roundtable on ReachMD, and I’m Dr. Charles Turck. Joining me to discuss how we can incorporate second-generation antipsychotics, or SGAs, into personalized treatment plans for patients with major depressive disorder, or MDD for short, are Dr. Michelle Scargle and Mr. Andrew Wargo. Dr. Scargle is the chief psychiatrist at Concord Health in Clearwater, Florida where she has been voted one of the best psychiatrists in the Tampa area in 2022 and 2023. Dr. Scargle, welcome to the program.
Dr. Scargle:
Thank you very much.
Dr. Turck:
Also joining us from Concord Health is Mr. Wargo, who’s a board-certified psychiatric nurse practitioner. Mr. Wargo, it’s great to have you with us as well.
Mr. Wargo:
Thank you for having me.
Dr. Turck:
Now before we get into developing care plans, Dr. Scargle, what role do SGAs play in the management of MDD?
Dr. Scargle:
They’re the only FDA-approved adjunctive medication for treating depression. If somebody’s on an antidepressant agent, for example an SSRI, and they’re not remitted with their depression, we can consider adding in an SGA to work towards treating the symptoms of depression that might be causing them trouble in life.
Dr. Turck:
And turning to you now, Mr. Wargo, would you explain the mechanisms of action by which SGAs are thought to augment antidepressant effects?
Mr. Wargo:
Yeah, so I think it’s important to understand that neurotransmitters in your body like serotonin, dopamine, and norepinephrine have a direct relationship with your day-to-day mood. First-line antidepressants, things like SSRIs and SNRIs, strictly work through serotonin and norepinephrine. The difference is if those are not being effective enough, you can add a second-generation antipsychotic as an augmenting agent. What that would do is modulate dopamine. Dopamine in second-generation antipsychotics can agonize in certain areas of the brain, increasing dopamine in certain areas of the brain like in the mesocortical pathway, which is responsible for lack of motivation, apathy, things like that. So adding a second-generation antipsychotic that does affect dopamine can improve symptoms of depression like lack of motivation, rewards, and apathy.
Dr. Turck:
Now given these attributes, Dr. Scargle, under what circumstances would a combination of an SSRI and SGA most likely be effective in managing MDD? For example, are there any patient factors or symptoms that may predict a favorable response to this approach?
Dr. Scargle:
Yeah. I mean clinically, I’ve been working with depression for 20 years, and I feel like I’ve used a lot of serotonin-promoting medications to help my patients. And you know what? They do help them. You know, people are not having the panic attacks anymore. They’re not having the uncontrollable crying. But what a lot of times I’m finding with some patients is they just don’t have joy; they don’t have motivation; they’re just going through the motions. So you’re thinking about maybe a mom that had depression and maybe she wasn’t working, and now she’s back to work but after work she comes home and sits on the couch and doesn’t do puzzles with her kids. She’s not engaging. There’s no zest for life, so I think for a long time, we’ve been satisfied with people not thinking about death so much, but I think we need to be more focused on how can we help them think more about living, and that’s where we may want to think about incorporating and augmenting with an atypical antipsychotic medication to really help with apathy, energy, and anhedonia—all those things that Andrew just talked about.
Dr. Turck:
For those just tuning in, you’re listening to Clinician’s Roundtable on ReachMD. I’m Dr. Charles Turck, and I’m speaking with Dr. Michelle Scargle and Mr. Andrew Wargo about second-generation antipsychotics, or SGAs, for the treatment of patients with major depressive disorder, or MDD.
So if we dive deeper into treatment approaches, Dr. Scargle, would you tell us about your thought process when developing individualized treatment plans that incorporate SGAs?
Dr. Scargle:
Absolutely. We’re always looking to treat the whole person in front of us, right? That’s the goal, and we never want to hurt somebody while we’re trying to help them. And so a lot of times, I’ll look at where they’re at. I’ll look at their other health conditions, and lots of times when we’re looking to augment, I’m going to try to find an atypical agent that maybe has a better side effect profile, maybe is not as much of a big offender for weight gain, or maybe it’s not going to be as likely to give somebody diabetes because all atypicals are not the same and not all atypicals have an FDA approval for depression augmentation either. There’s only some, right? So I’m just going to be thinking about just the overall person. I’m not going to want to give somebody typically an agent that’s going to be overly sedating because we’re trying to help them exercise and we’re trying to get them moving in their lives; I might look for a medicine that was maybe a little more promoting of wakefulness. So those are the factors: looking at their overall health, their lifestyle, and just thinking about their physical well-being as a whole.
Dr. Turck:
Now, Mr. Wargo, let’s say that we’ve got a patient on an SSRI plus an SGA. What characteristics do you monitor, and if needed, how and when would you go about adjusting the patient’s regimen?
Mr. Wargo:
First and foremost, I think it’s important to understand how these medications are metabolized. SSRIs and SGAs can be metabolized through the same liver enzyme; for example, fluoxetine is metabolized through the CYP3A4 enzyme in your liver. So when considering another SGA or second-generation antipsychotic, it’s important to see if that medication is going to be metabolized through the same liver enzyme, and consider possibly a lower dose because fluoxetine inhibits the metabolism of other medications that are being metabolized through that liver enzyme, so it can look like the other drug is actually a higher dose than what it is. So it’s important to consider how these medications, first and foremost, are metabolized through your body, and then monitoring the patient for different side effects. Commonly, some second-generation antipsychotics will cause weight gain, sedation, and other side effects, so going forward, it’s always good to get baseline labs, possibly a lipid panel and blood glucose on a patient because it also affects the blood glucose level in some second-generation antipsychotics, and then going forward to consistently monitor those things and see if that’s fitting for the patient because we never want the medication cons to outweigh the benefits.
Dr. Turck:
And if we stick with you, Mr. Wargo, for the final word, we know that adherence and persistence are absolutely critical to achieving therapeutic success. So how can we improve patients’ adherence to treatments like SGAs, and what long-term outcomes can we expect if we optimize treatment?
Mr. Wargo:
Most importantly, I think when developing any treatment plan with a patient, develop a good therapeutic relationship with the patient. Develop good rapport and good trust with the patient so that they have trust in you in making good medical decisions. Things that can help with that are involving the patient in their care. Presenting the options to them as far as medications, educating them on the possible side effects, educating on how the medications work, and letting them choose different options of what will benefit them.
Also going forward, I think it’s important to monitor side effects, things like weight gain like we mentioned, but another thing that’s more prevalent nowadays are people are becoming more acclimated to our movement disorders. Second-generation antipsychotics have a possibility to cause some movement disorders, things like tardive dyskinesia or Parkinsonian symptoms, so seeing the patient as a whole from head to toe and monitoring if they have any involuntary movements is critical because if a patient is taking a second-generation antipsychotic and it’s working for them but they’re having involuntary movements that are making them embarrassed, like you know their arm is moving rapidly when they’re talking to somebody in public, that’s going to cause them a lot of distress and consider possibly not taking the medication.
So I think it’s important to consider the side effects and movement disorders, especially nowadays when a lot of new treatments are coming out for things like the movement disorders. And going forward, you always want to see the benefits of the medication outweigh the cons. So unfortunately, medications do come with some side effects potentially, so making sure that medication is working for depression, increasing motivation, increasing enjoyment, and allowing them to get out and about in their daily life without having significant side effects like fatigue, weight gain, movement disorders, things like that. And just making sure that the benefits outweigh the negatives.
Dr. Turck:
Great comments for us to consider as we come to the end of today’s program. And I want to thank my guests, Dr. Michelle Scargle and Mr. Andrew Wargo, for joining me to discuss how we can incorporate SGAs into personalized treatment plans for patients with major depressive disorder. Dr. Scargle, Mr. Wargo, it was great having you both on the program.
Dr. Scargle:
Thank you.
Mr. Wargo:
Thank you so much. It was great being here.
Announcer:
This episode of Clinician’s Roundtable was sponsored by Abbvie US Medical Affairs. To access this and other episodes in our series, visit Clinician’s Roundtable on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!
