Now if we look at the first-line treatments available for MDD, those include selective serotonin reuptake inhibitors, also known as SSRIs, serotonin norepinephrine reuptake inhibitors, or SNRIs, and dopamine norepinephrine reuptake inhibitors.2,3 These treatment classes target one or two monoamine neurotransmitters out of norepinephrine, serotonin, and dopamine. But none target all three—which may explain in part why only about one-third of patients achieve MDD remission with first-line antidepressant monotherapy.2,4 In fact, approximately 50 percent of patients continue to experience unresolved symptoms after receiving first-line treatment for MDD.4-6
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These symptoms may include depressed mood, anxiety, concentration difficulties, changes in appetite, and low energy levels, all of which may impact patient treatment plans and the likelihood of remission.7-11
Now, I’d like to take a moment to talk about a recent survey of patients who didn’t achieve remission on antidepressant treatment. In patients who expressed frustration with their medication, one-third reported wanting to stop treatment, while 15 percent reported medication nonadherence.12 In addition to their impact on treatment plans, unresolved symptoms can also lead to poor prognoses.7 |
They can also be associated with increased economic burden, impairment of work and relationships, more chronic depressive episodes, and worsened functional outcomes.2,6,13 So, in my opinion, the need is clear for providers to be vigilant and pursue a targeted treatment approach early in the illness trajectory for patients with unresolved symptoms and those at risk of relapse. Additionally, we can personalize treatment plans by adjusting the current medication’s dose, switching to a different antidepressant, or augmenting current treatment with an additional agent. Non-pharmacologic considerations include adding physical exercise, cognitive behavioral therapy, or multidisciplinary care.2 Now regarding switching antidepressants, the STAR*D trial demonstrated the effect of switching antidepressant medications in patients who started on an SSRI. The trial showed that the rate of response diminished with each change to a new medication.4 And after the third treatment change, only 16.8 percent of patients achieved an adequate response.4 With that being said, some cases of an inadequate response to antidepressant monotherapy could require adding a second antidepressant.2 Augmenting with an adjunct medication, such as an atypical antipsychotic, is also an option.2 So by recognizing the need for early intervention, our goal is to reduce the time spent in a depressed state and potentially improve patient outcomes.7 ReachMD Announcer:
This program was sponsored by Otsuka and Lundbeck. If you missed any part of this discussion, visit ReachMD.com/industryfeature. This is ReachMD. Be Part of the Knowledge. References - Substance Abuse and Mental Health Services Administration. (2021). Key substance use and mental health indicators in the United States: Results from the 2020 National Survey on Drug Use and Health (HHS Publication No. PEP21-07-01-003, NSDUH Series H-56). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/
- Gelenberg AJ, Freeman MP, Markowitz JC, et al. Practice guideline for the treatment of patients with major depressive disorder third edition. Am J Psychiatry. 2010;167(10):1–152.
- Nutt DJ, Davidson JR, Gelenberg AJ, et al. International consensus statement on major depressive disorder. J Clin Psychiatry. 2010;71 Suppl E1:e08. doi:10.4088/JCP.9058se1c.08gry
- Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry. 2006;163(11):1905-1917. doi:10.1176/ajp.2006.163.11.1905
- Fawcett J, Barkin RL. Efficacy issues with antidepressants. J Clin Psychiatry. 1997;58 Suppl 6:32-39.
- Papakostas GI. Managing partial response or nonresponse: switching, augmentation, and combination strategies for major depressive disorder. J Clin Psychiatry. 2009;70 Suppl 6:16-25. doi:10.4088/JCP.8133su1c.03
- Nierenberg AA, Husain MM, Trivedi MH, et al. Residual symptoms after remission of major depressive disorder with citalopram and risk of relapse: a STAR*D report. Psychol Med. 2010;40(1):41-50. doi:10.1017/S0033291709006011
- Iovieno N, van Nieuwenhuizen A, Clain A, et al. Residual symptoms after remission of major depressive disorder with fluoxetine and risk of relapse. Depress Anxiety. 2011;28(2):137-144. doi:10.1002/da.20768
- Zajecka J, Kornstein SG, Blier P. Residual symptoms in major depressive disorder: prevalence, effects, and management [published correction appears in J Clin Psychiatry. 2013 May;74(5):519]. J Clin Psychiatry. 2013;74(4):407-414. doi:10.4088/JCP.12059ah1
- Romera I, Pérez V, Ciudad A, et al. Residual symptoms and functioning in depression, does the type of residual symptom matter? A post-hoc analysis. BMC Psychiatry. 2013;13:51. Published 2013 Feb 11. doi:10.1186/1471-244X-13-51
- Hybels CF, Steffens DC, McQuoid DR, et al. Residual symptoms in older patients treated for major depression. Int J Geriatr Psychiatry. 2005;20(12):1196-1202. doi:10.1002/gps.1418
- Mago R, Fagiolini A, Weiller E, et al. Understanding the emotions of patients with inadequate response to antidepressant treatments: results of an international online survey in patients with major depressive disorder. BMC Psychiatry. 2018;18(1):33. Published 2018 Feb 5. doi:10.1186/s12888-018-1625-y
- Arnaud A, Suthoff E, Tavares RM, Zhang X, Ravindranath AJ. The Increasing Economic Burden with Additional Steps of Pharmacotherapy in Major Depressive Disorder. Pharmacoeconomics. 2021;39(6):691-706. doi:10.1007/s40273-021-01021-w
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