Treatment Options for MDD

Gus Alva, MD, DFAPA: What do you consider regarding a particular approach for a given set of patients based on, say, their backdrop, disease severity, how long they’ve had the problem, what their h bracket might look like, or medical comorbidities, and is there a particular agent that you steer toward initially? And do you switch, augment? You touched on that to some degree, but what would be some of the [adverse] effects that you’ve run afoul [of]? Charles, and maybe Carmen subsequently, you can both opine on these topics.

Charles Montano, MD: I love Carmen’s comments on scales, and I love that you brought the RMS [Rapid Mood Screener] in, Carmen. I think it’s very quick and easy, and I attach it to the PHQ-9 [Patient Health Questionnaire-9]. I got to put a little bit of a bug in your ear, Gus, because if I attach it, it now becomes a PHQ-15. It reminds me that every time I have a depressed patient there’s approximately a 1 out of 4 chance that this is in the bipolar spectrum, and I need to think and treat directly. For me, that’s a necessary thing at the onset, at the beginning, and it takes the patient so little time; it’s 2 to 3 minutes tops. The positive predictive value is superb with 4 or more positives; even with 3, it’s pretty good. It reminds me, what about the other comorbidities? Depression doesn’t exist in a bubble; …many roads lead to depression and what are the other comorbidities that are there that are bringing this syndrome to bear on a patient? ADHD [attention-deficit/hyperactivity disorder] is another big one. I must look at that and consider is that adequately treated, and if it isn’t, adequately treat that once the main problems with the major depressive disorder [MDD] are under control. I’ve got to start to think about treating the anxiety disorder. Those are the different things that I think about in treatment

If I’m looking at enhancing or not reducing the dopamine activity in the brain, I’m not going to use a straightforward SSRI [selective serotonin reuptake inhibitor], I’m going to use a modulator. The 2 we have right now in this country are vilazodone and vortioxetine; vortioxetine is very precognitive. I think there are 5 different cognitive neurotransmitters; dopamine, epinephrine, serotonin, glutamate, and histamine are recruited by that drug. Not having to reduce dopamine activity will help someone who has underlying ADHD that is struggling to get through a day at work [or] with their family, or keep their job. I don’t want to interfere with that or cause cognitive dysfunction with an SSRI, so that makes me think if I can possibly start and get it right the first time, why not start with a modulator? Something that isn’t just a reuptake inhibitor, where more networks are involved. We [have] got to think about that.

Gus Alva, MD, DFAPA: Good. Carmen?

Carmen Kosicek, MSN, PMHNP-BC: Absolutely, exactly what Charles has said. The sad part is the reality for many of us is, can we get it? What’s the formulary access for insurance? Which is mind-boggling because we know even though it’s an older reference from [the] STAR*D [trial], that the more times you hop from [medication] to [medication], the less chance [there is] of efficacy. That is something that we need to be additionally mindful of. On the flip side of that is, when they present to you, you get an in-depth history. [You] might not be the first prescribing provider to put them on a [medication]; [you must] really dig. If that is the case, we’re just taking what the patient is telling us; it’s not on a PDMP [prescription drug monitoring program] that we must showcase where it’s at. I was taught to be a patient advocate and use current evidence-based practice. That is my goal because what if this was me? What if it was my family? What if it was my neighbor? I’m not here just to check the box and say we’re going to try––what did you say, 36, Charles?––we’re going to try out 36 first. I really want to go up strong out of the gates.

Gus Alva, MD, DFAPA: And the patient’s not going to stand for that. That’s the other thing. They’re going to give up.

Carmen Kosicek, MSN, PMHNP-BC: Correct. Or they’re going to hop from provider to provider, [and] it very well could be they’ve already been to someone else before they were with you. So really dig to find that out, [and] document it in your notes so that you’ll meet the PA [physician assistant] request in demand of the coverage for insurance. Also, the age, because there’s not yet very many [agents] that are officially indicated for [patients] under 18…. That is something sadly that we must be mindful of. Please also remember as a prescribing provider, you can’t just send newer agents to your local big box store. It would be no different if I was an oncologist. I wouldn’t think that it’s just randomly going to be on the shelves, the [medications] that I send. Often, it’s the hoops and hurdles of the providers not understanding––I call it super couponing––and they don’t know the step edit of how to get the new [medications]. They fall into this mantra that you can’t get them, which is absolutely not true. You can. Yes, they’re going to need a PA request, but the out-of-pocket spend is not indicative of the shelf price. No different on the generic [medications]. The last thing that I hear is this mantra against big pharma. Who do you think makes your generic meds? The same companies? You need to understand that what has been taught to you is a little outdated. We must realize that finally there are new agents in the CNS [central nervous system] arena to help all of us, like we said in the beginning. Look what our entire country and world has been through. We are the frontline help now and it’s time to help.

Gus Alva, MD, DFAPA: It's sad to say that with this whole COVID-19 pandemic, we’ve seen the number of individuals affected with MDD triple. It’s a very important theme.

TRANSCRIPT EDITED FOR CLARITY