Evolving Management Strategies in MDD: Smarter Choices After Unsuccessful First-Line Treatment
Since 2009, the prevalence of major depressive disorder (MDD) in adults has steadily increased. In 2020 alone, approximately 21 million people experienced MDD, with the highest percentage occurring in adults aged 18 – 25 years (17%). Currently, a combination of antidepressants and psychotherapy are used as a first-line treatment option. Still, some patients may not see symptom relief after weeks of treatment, and some do not experience relief at all. What options are there for your patients who see a failure in treatment?
Vladimir Maletic, MD, MS; Sarit Hovav, MD, FAPA; Gus Alva, MD, DFAPA; and Vanessa Joy Walker, a patient advocate, spoke about how to adjust the treatment and management of MDD to address the individual needs of patients, specifically when first-line treatment fails, during their session “Evolving Management Strategies in Major Depressive Disorder: Smarter Choices After Unsuccessful First-Line Treatment,” at the Psych Congress meeting in New Orleans, LA on Sunday, September 18, 2022.
To begin, the presenters outlined the prevalence of MDD in the United States, showing the societal and personal toll the mental health disorder creates on patients. Additionally, they explained the systemic health consequences of MDD and how the disorder causes an increase in mortality.
Next, they explained how MDD is primarily treated, the guidelines for when treatment fails, and what therapies can be added to the primary treatment of MDD. According to the 3 guidelines presented, a timeline of treatment should be followed before considering a switch to a new treatment or a treatment augmentation. The presenters shared a list of adjunctive therapies—second-generation antipsychotic agents and add-on treatments—that clinicians can consider when treating their patients. In some studies, results showed an increase in remission in patients when using adjunct therapies in comparison with monotherapies.
The presenters discussed how clinicians can determine whether to switch to a different antidepressant after failure or augment treatment based on Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 MDD guidelines. According to the presentation, switching a patient’s treatment is the best option if the patient presents significant adverse effects or if their condition worsens, but, in general, turning to adjunctive therapies provides a more favorable outcome. Further, the presenters shared how certain symptoms can influence the choice of treatment. For example, the use of bupropion—a norepinephrine-dopamine reuptake inhibitor—was shown to decrease fatigue and sleepiness in patients when compared to selective serotonin reuptake inhibitors.
In some cases, patients and clinicians may opt for non-pharmacological treatments. To close out their presentation, the presenters shared treatment options without antidepressants. Cognitive therapy and behavioral activation, for example, was shown to delay relapse in MDD, and changes in a patient's lifestyle—such as alcohol intake—can influence the risk of depression.
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- Maletic V, Hovav S, Alva G, Walker VJ. Evolving management strategies in major depressive disorder: smarter choices after unsuccessful first-line treatment. Talk presented at: Psych Congress 2022; September 17-20, 2022. New Orleans, LA. Accessed September 27, 2022. https://www.national.psychcongress.com/