Current Challenges With MDD Treatment Options

Gus Alva, MD, DFAPA: What do you think is the level of satisfaction for patients and providers with the available therapies that are excellent at the present time? And what are some of the challenges for both sets of groups?

Carmen Kosicek, MSN, PMHNP-BC: I don’t think it’s there. It’s the same thing that I’ve said before, that providers don’t understand that you must send newer agents to specialty pharmacies or they’re locked in formulary access, limited access. That takes a discussion. This is our license on the line. These are our patients, and having outdated formularies, it would be no different than in primary care. It takes a discussion by the providers. Sometimes it even takes providers. I do this myself, a quick email to utilization review of “here’s why I need access to these agents.” It’s not a dissertation, it doesn't even have to be sourced and referenced, just 3 or 4 sentences; but it’s imperative that we all engage at this level, so that we truly have access to medications to prescribe for our patients that are so needed. The lack of understanding of how to get the agents [is an issue], and then there are just a small handful of agents, but what is coming on the horizon? It is time right now to learn about what is there and to learn how to get them and to have that conversation wherever you’re working. This would be no different. I cannot imagine in oncology prescribing [medications] from 30 or 40 years ago just because that’s on the formulary. I cannot imagine someone in medical devices saying, “I’ll take that old knee replacement. I can’t bend it all the way, but that’s what we do here.” It is time for us in psychiatry to stand up and stand strong that the evidence is there, and it’s overwhelmingly there, and our patients deserve it.

Gus Alva, MD, DFAPA: Charles.

Charles Montano, MD: Beautifully stated.

Gus Alva, MD, DFAPA: Talk to us about residual symptoms and the impact on quality of life for patients and [adherence].

Charles Montano, MD: The reason for doing repetitive screening with a PHQ-9 [Patient Health Questionnaire-9] is going to bring that symptomatology out. Do they have a primary sleep disorder that will show up? Do they have ADHD [attention-deficit/hyperactivity disorder]? Believe it or not, 2 of those questions will often show up when you’re doing a PHQ-9. So not forgetting that this disease is chronic recurrent, that’s how I think of it, and that you need to keep screening. When you find residual symptoms or poorly treated symptoms, just as Carmen says, even if you yourself must get online with a medical director and say, “This cannot continue the way it is; the patient needs this and thrives with this in comparison,” I think that’s important. Other issues that come up––Carmen, you raised an important theme, and that is trying to keep the minimum number of medications on board so that you don’t have iatrogenic depressive effects and iatrogenic problems with [adverse] effects. That’s important, but unfortunately there’s not a lot of guidance for that. We must have deep, rich educational programs, especially in the primary care setting, [for] nurse practitioners [and] Pas [physician assistants], as they’re often the ones that are turned to in the practices for managing the most difficult patients with MDD or [patients [with] bipolar or mixed bipolar [disorder]. We need more of that. We need a greater ability to educate those folks who are given the burden and privilege of treating this disorder. This is a feel-good disorder; you feel good when you’ve restored that patient, you feel good when you know their families are the recipients as well. It’s one of the most important things that we can treat as providers. I have problems in my clinical trial practice side with placebo effect because I must be very flat in my delivery when it comes to giving the Montgomery-Asberg Depression Rating Scale [questionnaire], et cetera, but it’s important that we know that we have a huge impact as practitioners and that it is up to us. If we don't treat it and treat it appropriately, who…else is going to do it?

Gus Alva, MD, DFAPA: I love the examples that you both gave, very practical in nature. One other one that I would add: Many years back, a good 25 years ago, [Dr] Mark Rappaport first said––and I’ll tell you I’ve emulated it since––I oftentimes will ask a patient, If there were 3 things that you’d want different right now, what would those be? That’s akin to what you were describing, Charles, with that visual analog on a scale of 0 to 10––where exactly are you at right now. And that comes back to Carmen’s point of utilizing digital hardware now, and certainly screeners and additional things.

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