Timely Interventions: Managing Partial Response in Major Depressive Disorder

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:
Welcome to Clinician’s Roundtable on ReachMD. I’m Dr. Charles Turck, and joining me to discuss the importance of timely intervention for managing partial response in 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, thanks for being here today.

Dr. Scargle: 
My pleasure. Thanks for having me.

Dr. Turck: 
Well, to start us off, Dr. Scargle, would you define partial response in MDD and its clinical implications?

Dr. Scargle: 
So with partial response, the patient’s going to feel better than they did before. You might see the numbers go down on their PHQ-9 or their MADRS score. We like that. We like to have those types of firm measures and see improvement, and you might see the patient functioning better. Maybe they were not able to work before or they were on partial leave from work, and now they’re able to go back to work. So they’re functioning better, they’re not as depressed, and they’re not crying as much, but at the same time, there are many symptoms that define depression aside from just feeling sad. There’s concentration issues, and lots of times when people’s depression is partially treated, they’re still having issues with concentration and some cognitive issues. They may still have still diminished energy. Oftentimes, people are still suffering from anhedonia, which is basically the lack of being able to feel joy. They are going through the motions. In my mind, that’s kind of the picture of partially treated depression, just going through the motions in life.

Dr. Turck: 
Now in trying to address this complicated issue, what are the risks associated with prematurely switching a patient to another antidepressant?

Dr. Scargle: 
Well, you’ve gained some benefit on the first antidepressant that if you change prematurely, the second one you choose might not work as well as the first one. And you’re also going to have to wait 6 to 8 weeks to see if that one’s going to benefit. And you’re going to lose the benefit that you’ve obtained because oftentimes when you’re changing antidepressant medication, you may have the depression get worse before it gets better again. And with the first medication that they’re taking, they’re aware of the side effect profile. That one does seem, if they’re still taking it, like it’s tolerable, right? It’s just not, on its own, enough to get them well.

Dr. Turck:
And on the flip side, how can delaying intervention with adjunctive therapies impact long-term patient outcomes?

Dr. Scargle: 
It has big impact. I mean, it really does. For one thing, it’s a travesty for patients to not be able to feel joy, to not be able to look forward to things, or to engage in their life fully. That’s a travesty for the patient, but it also implicates other factors as well. When a patient has partially treated depression, they’re not going to be as emotionally available for the other people in their life. And so they might sit on the couch with their spouse but not engage with them or have conversation. They might not be engaged sexually with their spouse because they just don’t have any interest in that. A parent may be going through the motions and taking care of their child. They’re going to the store, they’re cooking the dinner, and they’re washing the clothes, but they’re not getting on the floor with their kids and doing puzzles or playing cards. They’re not building those memories, and that’s what life’s about, really.

And professionally, it can also have big impacts. The symptoms of depression go beyond just feeling sad. People can have concentration issues as residual depression. They, again, are not going to be as socially engaged. They’re going to be a little bit more laid back, a little bit more reserved, right? There’s cognitive symptoms that might be present when people have refractory depression, and so you’re not going to be able to be your best person on the job. So when it comes time for promotions, you might be the person that gets passed over because you’re not as engaged, you’re making more simple mistakes at work, and you’re just not the person that’s leaning in, right? You’re not the person leaning in, so partially treated depression can have big impacts in a patient's life.

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 consequences of hastily switching antidepressants as well as the risks of delaying adjunctive therapies in patients with major depressive disorder, or MDD.

So, Dr. Scargle, now that we know why we have to avoid delaying action when it comes to treating patients experiencing a partial response, what recommendations do you have to implement timely and effective treatment interventions?

Dr. Scargle: 
Just make sure you’re asking your patients when they come for appointments about other factors in their life beyond how are you doing with the medicine. Just ask them, “What’s the last thing that you did that made you laugh?” or “What did you do last weekend?” Well, if they’re telling you they stayed home by themselves and watched television and they didn’t go to the family event they got invited to, that gives you a hint that you might want to think that the patient’s not as well as they could be and maybe we should talk about augmenting. At least give them the option to feel better than they do.

Dr. Turck: 
And what kind of education and counseling points do we need to effectively communicate to patients and their caregivers to help overcome barriers to timely treatment adjustments?

Dr. Scargle: 
Well, I always tell people that I want to help them using the least amount of medication we can get away with. But I might say to a patient who had partially treated depression, “Look, it seems like you’re better, but are you feeling as good as you want to feel? Do you want more than this? Are you, as a patient, satisfied with how things are going with your treatment for depression?” And I’ll tell them, “Look, I have a tool that you can try if you want to to see if it improves your depression." Typically, these boosters—I nicknamed them boosters—are going to work quickly for you. And so if you want to let this medication audition for you to see if it earns the right to be in your body, we can do that. If you have any questions or concerns, if you choose to try it, then obviously call me, we can talk about it. But I don’t want you to leave my office without the option of feeling better than you do if you, as a patient, are not satisfied with how you’re feeling.

Dr. Turck: 
And lastly, Dr. Scargle, are there any key takeaways you’d like to leave with our audience about partial response to treatment in MDD?

Dr. Scargle: 
It’s more common than what we imagined. And I remember a day when I recognized for myself that I had been satisfied with my patients being apathetic. I would have them come in, and I would say, “Okay, are you feeling better?” And they say, “Yep, I’m feeling better.” And I feel like, okay, my job’s done, they’re doing better. But I think we have to really dig deeper for our patients. Patients come in sometimes to the office, and they want to please us. There’re so many patients that come in, and they don’t want to complain about, “Well, I don’t feel as great as I want to.” They’ll just say they’re doing okay. And they may not actually know that anhedonia or ongoing concentration problems or ongoing social isolation are still symptoms of depression, and so I feel like, as a clinician, I’m doing a better job now because I’m aware. And now we have tools we can actually use to get them past the point of just being less depressed but still apathetic. I want more for my patients, and I want to make sure they’re aware that they can feel better, too.

Dr. Turck: 
Well, as those final comments bring us to the end of today’s program, I want to thank my guest, Dr. Michelle Scargle, for joining me to discuss how we can ensure timely intervention for patients treated for major depressive disorder who are experiencing a partial response. Dr. Scargle, it was great having you on the program.

Dr. Scargle: 
My pleasure. Thanks 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!