Expert Perspectives on Advances in the Management of Major Depressive Disorder - Episode 4
Sagar V. Parikh, MD, FRCPC, leads a discussion on patient engagement and shared decision-making in treatment selection in MDD.
Andrew J. Cutler, MD: I really love where you're going with this. This notion of patient engagement and shared decision-making has become much more commonplace now. And I think to be able to do that, you really do have to understand the patient and take into account their preferences, their values, their preconceptions, the way that they think about these things, and how psychologically minded they might be, for instance. What have they heard from family members or friends, or what have they read on the internet? You alluded to this earlier. There's a lot of interesting information on the internet, some not so helpful. Let's talk about how we set treatment expectations. Greg, you talked a little bit about goals. How do we think about setting expectations and goals for the patient?
Gregory Mattingly, MD: So, once again, with patient engagement in mind, the first thing I always say is, “Listen. I’m going to listen to you but you’re going to guide me. I’m going to listen to you, you’re going to guide me, and we’re going to stick together to get you better. The goals are wellness. It’s not being less ill, it’s becoming well.” One of my analogies quite often, Sagar, is I'll talk to my patients and I'll say, “You know, our life is like a book, and in the same way that a book has different chapters, our life has different chapters. As we look forward, what would you like this next chapter to be?” Maybe that's more engagement with family? Maybe that's better control of their temper? Maybe that's not crashing into low periods where they get isolated and don't feel like doing anything with anyone. So, how do you engage your patient as you talk about those treatment options? I would say that one of the limitations of depression treatment is quite often we get into a chronic pain model. Instead of talking about wellness, we talk about being less ill. I've never had a patient say, “I want to be less depressed.” They come in and say, “I want to be well.”
Andrew J. Cutler, MD: I want to feel like myself again. I want to enjoy things. I like that you're focusing on the positive idea, Greg. Sagar, I guess one other thing we need to confront too, guys, is while it's important to set these treatment goals, and of course, for most patients, we want them to stay on their treatment, the treatment of depression more and more is not a quick fix or like treating infectious disease. It's more of a chronic management where we have to confront the fact that patients don't always keep taking their medicines. How do we deal with that challenge, Sagar?
Sagar V. Parikh, MD, FRCPC: Well, to amplify the issue, how do you know you're better, I always say, “When you're sick, you usually pull out the thermometer and check your temperature. The PHQ-9 [patient health questionnaire-9] and things like that are just the psychiatric equivalent of a thermometer. And we want to know that you're better both by what you say, but also by some other metric. And that's why we've talked a lot about so-called measurement-based care, but all this is is using a thermometer to measure how your depression is doing, and using it as a clue if you're stuck, if your temperature remains high, do something different in the treatment.” So the first principle is to make sure that they buy into the idea that regular use of some rating scale is a necessary thing. And both in my personal experience as well as in what I've read in the literature, patients don't think that using a rating scale is some clunky thing or an excuse by the clinician to not pay attention. Actually, they think the reverse, they respect the fact that clinicians use scales as a more precise way of gauging progress. I think that's the first thing. The second thing about engaging the patient is you've investigated what their theory of depression is as well as where they want to go. And just outlining the options and making it clear in the shared decision-making paradigm that there are 2 or 3 ways that you could achieve wellness. Broadly speaking, the different modalities like psychotherapy or medication, or a combination thereof. And what do you want to try first? I try to give them specific advice. So for mild to moderate depression psychotherapy and medication are roughly equal. For severe depression, medication is both faster and probably more efficacious. And of course, using both together is better for severe depression. But for mild depression, you don't really need to use both. It's good if you do, but from an evidence perspective, you don't need to combine treatment for mild to moderate depression as much as you do for severe depression. I try to do it step by step and then as they clarify, I'm willing to consider medications, then again, I'll go into the next phase which is let me tell you about 3 medicines. Typically I choose 3 different medicines from 3 different classes. And I explain the pros and cons of each medicine, and then I ask them what they want to hear more about. And then I go from there.
Transcript edited for clarity