Managing Partial Response in MDD Care: The Role of Adjunctive Therapy

Announcer:
You’re listening to Clinician’s Roundtable on ReachMD, and this episode is sponsored by AbbVie US Medical Affairs. Your host is Dr. Charles Turck.

Dr. Turck:
Welcome to Clinician’s Roundtable on ReachMD. I’m Dr. Charles Turck, and joining me to discuss adjunctive therapy for patients with major depressive disorder, or MDD for short, is Dr. Michelle Scargle. She’s the chief psychiatrist at Concord Health in Clearwater, Florida, where she’s 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 for having me.

Dr. Turck: 
So starting with some background, Dr. Scargle, just how common is it for patients with MDD to have an inadequate or partial response to treatment? And what signs should we be on the lookout for?

Dr. Scargle:
It’s very common, and for us clinicians that have been practicing for years, it’s something that we’ve kind of been accustomed to. In the past, we’ve only had medications that might help people improve their depressive symptoms so they don’t feel as sad. They’re not crying as much. They can get back to work. They don’t have as much anxiety. But oftentimes, I’ll have patients tell me that they feel less depressed, but they also don’t feel as much of anything. They have residual apathy. They have anhedonia. They’ll talk about going to do things that should make them feel happy, and they don’t feel happy. They don’t feel anything. And for years, I think we’ve been sort of complicit; we’ve been okay with that being the best we can do for depression. But I think many patients are still kind of half-fixed. They’re improved, but they’re not living their life; they’re not well.

Dr. Turck: 
And with all of that in mind, would you tell us about the role of adjunctive therapy and addressing some of these challenges in MDD treatment?

Dr. Scargle: 
I am so thrilled that we have more tools in our toolbox. I’ve been practicing psychiatry for 25 years, and years ago, we didn’t have as many tools in the toolbox to offer as help for patients, right? But now, thank goodness, we have more research; we have more augmenting agents, right? And so I really value the fact that we can now offer patients more because patients want more.

Dr. Turck: 
So what do we know about the latest evidence-based adjunctive treatments available for MDD?

Dr. Scargle: 
So in psychiatry, we’ve been using adjunctive medications for many, many years. I mean, back in the day, we used to sometimes use lithium to augment antidepression medication, trying to get our patients beyond being half better. Many of us have used bupropion to augment an SSRI or SNRI in the past. But you know STAR*D showed that that really is not effective for augmentation for depression.

So, thankfully, in the 2000s, there started to be more interest and research looking at augmenting antidepressant medication with an atypical antipsychotic. And several of these medications have gone on to do clinical trials and have achieved FDA approval in indication as augmenting medications for depression.

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 about the role of adjunctive therapy in treating major depressive disorder, or MDD.

Now if we switch gears a bit and focus on implementing adjunctive therapies into clinical practice, Dr. Scargle, how do you select appropriate patients and counsel them on this approach?

Dr. Scargle:
Well, I ask my patients how they’re doing, and I go beyond asking how’s their depression. I ask more about functionality. And I ask them, “Hey, what do you have in your life that brings you joy?” “What do you have in your life that you’re looking forward to?” “How are you engaging with the people around you?” So I try to screen and ask deeper questions than just, “How is your mood today?” Because I want to know more.

So if a patient really is better than what they were with their antidepressant, but clearly, they’re not fixed yet, they’re not engaging with people. They don’t have joy in their life, right? Then I might tell them, “Look, I have other tools I can offer you; if you want to let them audition for you, that may do a better job for you. I think we can make you feel better than what you do now.”

And so at that point, I might educate them about the role of using an atypical antipsychotic as an adjunctive medication to try to remit their depression because we can now, and in years past, we may not have had that option with the tools we had available as clinicians. But now we have more and better tools so we can work towards remission.

Dr. Turck: 
And are there any safety concerns we should be aware of that might affect how we monitor patients?

Dr. Scargle: 
The goal is we’re treating the whole human being in front of us, and we never want to hurt somebody while we’re trying to help them. And so if there were other comorbid health conditions, like if someone has an unstable heart condition or maybe they have a cardiac arrhythmia, you might want to get cardiac clearance before you just decide to add the atypical antipsychotic medication.

You want to also look at, especially when you’re choosing which atypical might be the best one for augmentation, their labs and see if you know how their blood sugar is doing. How is their cholesterol?

You want to look at their weight because there are definitely differences. Some atypicals are a little more promoting of weight gain than others, and so you want to be thinking about the whole person. But by and large, the dosing that we use for augmenting for depression is low. And by and large, they’re very safe to add unless there’s some premorbid health condition that would preclude use of those medications.

Dr. Turck: 
So there’s a lot to consider when it comes to applying adjunctive therapies into MDD care, but just to bring this all together before we close, Dr. Scargle, from a high-level view, just what kind of impact can adjunctive therapy have on our patients with MDD?

Dr. Scargle: 
I mean, it can be incredibly beneficial for patients. And look, we only have so many days on this planet, we really do, and I think that if people are functioning on their antidepressant when before they were not functioning but they don’t have joy and they’re not able to really live their life, I mean, that’s why we come to work every day as clinicians: to make peoples’ lives better, and I don’t think that we have to settle.

And some people may choose not to try augmenting agents. And they may choose not to try the atypical, and that’s understandable, but I think as clinicians, we need to be more proactive in letting patients know that the option exists. We do a lot of auditioning in my clinic.

If you have a patient that maybe is not remitted, they’re just sort of better with their antidepressant, sometimes I’ll throw it out there and say, “Look, I have this medication which could potentially really improve your depression. If you want to let the medication audition for you, you can try it for 2 to 4 weeks, and then you come back and tell me if it earns the right to be in your body. And if you don’t like it, you don’t have to take it,” but I think we have to at least give the patient the option to feel better because we can now.

Dr. Turck: 
As those comments bring us to the end of today’s program, I want to thank my guest, Dr. Michelle Scargle, for joining me to discuss adjunctive therapy for patients with major depressive disorder. Dr. Scargle, it was great having you on the program.

Dr. Scargle: 
My pleasure. Thank you for having me.

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!