Undertreatment in Patients Suffering From MDD

Greg Mattingly, MD: What do we know about patients out there that are struggling with depression? We know that it’s one of the number 1or 2causes of a disability all around the world. Right now here in the United States, we know that levels of disability have gone up in the last 5 to 10 years, not down. So what do we know about people getting treatment? Are we doing a good job? Are we being aggressive about managing this? Are we making sure we find the right people and getting the right treatments? How are we dealing with treatment these days?

Jeremy Schreiber, MSN, PMHNP-BC: That’s a great question as well. I talk a lot to my students about how we’re managing depression and I always tell the students that we must be very, very vigilant. Some other disorders have kind of had more of a limelight recently and maybe not depression. Depression needs to have that limelight. Like you said, depression is one of the leading causes of disability. Obviously if patients are disabled, their functioning levels have declined and all of that. What we need to do is get our patients there. But part of the issue is that our treatments may not yield the results that we want them to yield. On top of that we have issues with adherence with our patients even taking the medications and this is assuming that patients even come in for treatments. Some patients don’t even know where to go. We think about getting these patients into our office, treating these patients, trying to get their symptoms cured, or to an absence thereof as rapidly as we humanly can. We have a couple challenges, right? We have insurance barriers. We have sometimes challenges with getting these medications into our patients in terms of affordability. When we look at the overall treatments, there’s a lot [of treatments]. Let’s call them numerous. A lot of these treatments all kind of play on the same playground. They’re all affecting the monoamines. We don’t have a lot of other treatments that can affect some other systems that we’re really looking toward now. So in terms of our treatments, I think we’re doing the best job we can. At least a lot of us are. I don’t think that we’re where we need to be yet with our patients.

Greg Mattingly, MD: So Jeremy, I just presented [at] this year’s American Psychiatric Association. A study that my good friend Roger McIntyre [MD, FRCPC – University of Toronto] and I did, where we asked patients who are part of the Depression [and] Bipolar Support Alliance, DBSA. So these are 800 or so people that are struggling with depression. They’re already on a treatment and we measured if they had moderate depression or severe depression. What was the level of functional impairment? What was interesting is both moderate and severe depression people were not functioning well. They weren’t functioning well at home, in school, and work. Moderate depression is still having severe impact in people’s lives. What was different is the severe depression. The train wrecks were likely to come into your office and ask for a change. Yeah.They’re a train wreck. I’ve got to do something different. The moderate depressions who are having functional impairments, they weren’t functioning well, were only a third as likely to ask for a change. Only 1 out of 3 ask for a change. What happens is they’re struggling in silence. They’ve gotten used to putting up with it. “This is the way I feel. I don’t look forward to the future. I don’t want to do things with people. I’m isolated. I'm not motivated the way I used to be, but I’ll just put up with it. This is my new normal.” And so I think it really drives home the fact that residual symptoms, moderate depression, functional impairments quite often struggle in silence. I think it brings home a lot of things. First of all, make sure you ask. Make sure you offer change. Try to prescribe with hope. But then, I know you’re a fan of this, when you measure symptoms, it’s just like measuring blood pressure or blood sugars. It makes sure you don’t forget people that are still struggling in silence.

Jeremy Schreiber, MSN, PMHNP-BC: I wholeheartedly agree with you. That’s one of the nice things about the utilization of rating scales in clinical practice as well. Because so often patients may come into the office and they may be like, “Oh, I’m doing OK and I’ve been going to work but I’m still sleeping a lot, or I’m still overeating.” The other thing that happens, too, that I found, is sometimes when people are doing a little bit better, so say not in remission but a little bit better, their irritability may decrease a little bit. Things at home are a little bit better. And they come in and they say things to us like, “Well, me and my partner are getting along better. I’m able to get to work. I’m able to do these things.” But they still might not be going to do the things that they enjoy. Or they still have these other symptoms, so they tell us they’re a little bit better and we as providers, we celebrate this and we cheer and we go, “Oh my goodness, this is so great.” The patient’s doing a little bit better because they were up here but then they fell down and we got them back up. But we didn’t get them all the way to here. Even getting patients to here sometimes is a huge victory. That huge victory is something that sometimes we settle for and it’s not something we should be settling for. We should be trying to get our patients to full remission. Right? That’s of course the goal. Like you said, it’s the suffering in silence. That’s one of the beauties of rating scales, it allows us to look and then have these numbers that we can track, and we can trend over time in these sorts of things. I don’t know that all providers are necessarily as thorough in the interview. We’re not all created equal, so to speak. The other thing is that we also have time constraints that may cut into our assessment ability.

Greg Mattingly, MD: 100%. Jeremy, I know that you and I are probably the same in that we each have good days and bad days. There’s some days where I’m a little more stressed. There’s some days where I’m a little more pushed for time. And by using those mental health vital statistics, getting the PHQ-9 [Patient Health Questionnaire-9] and the GAD-7 [General Anxiety Disorder-7], it makes sure that even on one of your tough days, one of your rush days, you’re not letting things fall through the cracks.

Jeremy Schreiber, MSN, PMHNP-BC: Exactly.

TRANSCRIPT EDITED FOR CLARITY