Transcript:
Hi there, my name is Kate Sullivan, and I am a psychiatric nurse practitioner. Today I will be discussing the complex and challenging course of major depressive disorder, or MDD. While the field of psychiatry has made great progress in managing and treating MDD, there remain limitations to achieving adequate disease control, especially in vulnerable groups that are difficult to reach.
First, we will characterize the lifetime course of MDD, including its etiology, and discuss disease management. Then, we will review gaps in our current knowledge where further research is needed.
[0:42] As you know, MDD is a leading cause of disability worldwide, as the condition significantly interferes with daily functioning.
Patients with MDD can experience a depressed mood, loss of interest or pleasure, psychomotor agitation, loss of energy, changes in weight/appetite and sleep, feelings of worthlessness, indecisiveness, and/or recurrent thoughts of death. They also have a higher risk of suicide compared to the general population.
Symptoms can be quite debilitating, and symptom severity is correlated with functional impairment. We also know that impaired functioning is a predictor of subsequent disease relapse.
While there are many ways to evaluate MDD symptoms, I find it can be helpful to ask patients to complete the Patient Health Questionnaire-9, otherwise known as the PHQ-9. This standard assessment form is brief yet covers key MDD criteria and can be completed in the waiting room. Reviewing these results with patients can help me to better assess their symptoms and make an accurate diagnosis.
To better understand the course of MDD, let’s take a look at the etiology of the disease and how we can utilize different treatment approaches.
The cause of MDD appears to be multifactorial, involving disruptions in neurotransmitter systems, stress caused by life events, and cognitive vulnerabilities. We also know that genetics may play an important role in risk of the disease. MDD impacts the body as a whole, as patients are more likely to have additional medical comorbidities.
Now before we go on to discuss disease management and treatment, let’s take a look at the overall course of illness for MDD. On the left, you can see that the curve starts with euthymia, characterized by an absence of mood disturbance, or rather psychological well-being. This is the point at which MDD symptoms are not expressed and therefore do not require treatment.
As we move to the right on the graph we see the curve drop, signifying progression to illness and expression of symptoms that fit the DSM-5 criteria for MDD that I reviewed earlier.
[3:02] Following the curve in the graphic to the area above the point of disease progression, you’ll see that the goal of treating the acute phase of MDD is to induce a response to therapy.
According to the APA clinical guidelines, providers should consider initiating psychotherapy as well as starting a patient on an antidepressant. The guidelines also recommend allowing for a trial of 4 to 8 weeks for the treatment to take effect. After this point, providers should assess treatment response and side effects.
Early diagnosis and treatment optimized to each patient’s needs greatly increases the chance of achieving full functional recovery.
When developing a treatment plan, it’s important to take into consideration patient and family history, past responses to therapy, and severity of depressive episodes. In addition, age, gender, and comorbidities should also be factored into choice of treatment options.
As you may know, antidepressants could potentially have a delayed onset of action which can be challenging for both providers and patients. If you’ve tried different approaches without positive results, I would discuss with my patient other medications they make be taking to see if drug-drug or drug-food interactions are impeding medication absorption. It‘s also important to assess tolerability and medication adherence at follow up visits.
[4:34] Looking back again to our graphic, you can see that the course of MDD is marked by cycles of remission and recovery punctuated by possible relapse or recurrence.
Remission is considered to be a period of time where a patient does not experience MDD symptoms, whereas recovery is a more sustained period, when the depressive episode has ended. Relapse is a return of symptoms within the depressive episode, while recurrence would be regarded as a new episode entirely.
Once a patient has experienced their first episode of depression, there is a greater than 50% chance that they will experience a second episode; and, in those who experience a second episode, there is about an 80% chance that they will experience a third.
Patients in remission are considered to be undergoing a healing process and are not yet believed to be fully recovered, making them vulnerable to relapse. Patients who have recovered have a lower rate of recurrence. These differences are important to consider at follow-up visits since a longer duration of remission indicates the patient is more likely to achieve full recovery.
While there are many ways to determine if a patient has indeed achieved remission, such as using tools like the PHQ-9, it’s important to evaluate several factors to ensure that the patient is in full functional recovery. These can include the patient’s ability to cope with stress, quality of life, overall well-being, and a sense of return to their state of mental health before the depressive episode.
Long-term maintenance therapy is aimed at preventing relapse and recurrence. This requires close monitoring of MDD symptoms and may necessitate updates to the treatment plan.
If I had a patient who responded to initial therapy and achieved remission, I would continue to monitor their symptoms at follow-up visits. It’s not always easy for patients to recognize when their symptoms are recurring. Since starting treatment early after symptoms emerge is so important, I try to help them identify signs and symptoms that could indicate another MDD episode.
[6:52] To summarize our discussion today, MDD is indeed a complex and challenging disease that requires monitoring, re-assessing, and evolving treatment approaches.
It’s important to explain to your patients just how complicated the course of MDD can be so they can be prepared for the possible ups and downs associated with the journey. Setting this up at the first visit can greatly help patients understand what they might expect as a plan is initiated and modified over time.
Further research is needed to help providers like us better manage our MDD patients and increase their chance of achieving remission, preventing relapse, and improving outcomes.
