Monitoring Recommendations in MDD

Andrew J Cutler, MD: Let’s talk about switching our treatments and how we treat MDD [major depressive disorder] in specific populations. Sagar, can you tell me a little bit about some of the monitoring recommendations in MDD? We talked a little bit before about using measurement-based care, but what advice do you have to help clinicians monitor their treatment?

Sagar V Parikh, MD, FRCPC: So knowing what’s happening is both having a tool to measure how you’re doing, but also knowing when to do it. For instance, in our electronic health record at the University of Michigan, we have it set up so that PHQ-9s [Patient Health Questionnaire-9] are automatically requested from the patient either every month or every 2 months, so they don’t have to be done at every visit. They’re done on their own frequency. Now, the computer is smart enough to know that if somebody is coming in for a visit soon, they just link it to the visit. I think the notion that you do need a periodic check is really important. What also excites me is the fact that there are a number of apps that have been developed, and some of them have made it past the first level of research, but none are good enough to implement totally yet. But they look at 2 things. They look at how much you’re moving and how you’re talking. So you put this app on your cell phone, and it does not analyze or understand your words, but it understands the cadence and the frequency and the volume of your speech, and that’s 1 parameter. And if it detects you are slowing down, it sort of says, “Oh, this guy is getting depressed.” And similarly, if your step count goes way down, it starts to wonder. And so various algorithms are under development to validate, maybe even a composite of some speech changes and some mobility changes, all monitored passively through your cell phone as a warning sign maybe you’re getting depressed. At the very least, let’s administer a PHQ-9 again, the cell phone can do all this and then send the result to the clinician. I’m really excited about these kinds of passive things because all of us find it hard to remember to go take our temperature or blood pressure or do the PHQ-9, especially if we’re feeling OK, or we don’t have an appointment coming up. So if we can use more background measures, I think that’ll be really useful.

Andrew J Cutler, MD: Sagar, I’m seeing in clinical trials now what you’re describing, we call EMA—ecological momentary assessment. And it is remarkable the amount of data your cell phone contains. And these things not only monitor what you mentioned—your activity, your sleep, your prosody, and your speech—they can also measure how often are you interacting with social media, how often are you texting people, taking phone calls, or emailing. It really is opening up a whole new door of monitoring. Greg, what about the flip side? How about monitoring for adverse effects? And how do you even counsel patients and tell them about the adverse effects of these different kinds of treatments?

Gregory Mattingly, MD: Once again, I think Sagar said it 100%. We’re on this journey together. I’m going to listen to the patient and they’re going to guide me. So here are the side effects that we may encounter with these treatment options we’re thinking about. This 1 medicine that’s been very effective for depression tends to potentially have weight gain or sexual side effects, and this other medicine, which equally effective for depression, tends to help your energy but can make some people anxious. So let’s talk about what are the side effects that would be potentially favorable to you. And I think one of the future treatments is going to be, let’s talk about side effects that you may have to get through not on a chronic basis, but have it on a 2-week basis, or an intermittent basis. Even right now with esketamine in some ways. That’s the discussion—the episodic adverse effects. Say, they took it about 40 minutes, and they’re usually gone by 2 hours. Episodic adverse effects are something we’re not used to talking about, but with a lot of our newer treatment options, it’s going to be what are the adverse effects while that medicine is in your system? And then what are the adverse effects in the long term if we need to use that medicine again?

Andrew J Cutler, MD: Now, that’s an excellent point. Patients or people, in general, don’t like surprises. I think it’s important to warn them of the most common adverse effects. And what’s our plan? What are we going to do about it? Because adherence to the treatment is very important, depending on how long you’re supposed to take it.

Gregory Mattingly, MD: Andy, one of the things I’ve recently come up with, and we’ve talked about this, for 20 years I’ve talked about switching and switching strategies, and written articles about it. I don’t talk about switching strategies anymore. I talk about starting strategies. When you switch a medicine, the patient, when you ask a patient, what’s your inherent emotional reaction? The word switch brings up fear and concern; what if I get worse? What if it doesn’t work? If you do the same thing, but you say, “Listen, I’d like to start you on something, you can feel better than where you are.”

Andrew J Cutler, MD: Starting with something different, maybe.

Gregory Mattingly, MD: I’d like to start you on something because I’ve seen people like you do really well with this treatment option, or I think it may be the right fit for you. The emotional reaction of those same patients, instead of being worried and anxious, is feeling hopeful 95% of the time. So I now talk about starting on a different treatment journey.

Andrew J Cutler, MD: Sagar, let’s talk a little bit about that. When would you consider, rather than switching, starting a new medication? Or when would you consider augmenting? You talked a little bit about this earlier.

Sagar V Parikh, MD, FRCPC: I just want to add something to what Greg said, and that is, it’s not only warning the person or asking them about adverse effects but there was early research out of the University of Washington that said, simple messages change people’s behavior. And those simple messages are, if you’re having adverse effects, reach out to me, and let me know. Because many times, anthropologists have certainly demonstrated this, patients don’t want to disappoint their clinicians. So they don’t want to say, “Oh, I’m sorry, but that very nice gift you gave me of some fancy medication, it actually caused me an adverse effect, and sorry, but I didn’t like your gift.” So people are reluctant to really present their side effects. So instead, if we make it positive—and this is what they did with the studies out of the University of Washington—they explicitly told the patients, to let us know in 2 weeks what’s going on. If you’re having side effects, if you’re having other problems, tell us and we will respond. And so I’ve tried to operationalize that in my practice by saying, we have electronic health records and the preferred way for patients to communicate with us is through the portal. So they send us a confidential message through the portal. And I say, with every medicine I start, I say, portal message me in a week with just a simple message: tolerating OK/not tolerating OK, or didn’t get it or something like that, just so I know what’s going on. And you know what, many of my patients take me up on that. I think giving them permission to be more engaged makes them more engaged. And then I feel like I’m more on top of things.

Andrew J Cutler, MD: That’s really helpful advice. I really appreciate that. And you’re right, I mean, letting them know that we always have a plan here, we have options, we have alternatives. I think to Greg's point, that instills a sense of hope. And then giving the patient permission to say things to us, empowers them, activates them, and engages them in the treatments, which are all things I think that we want to do.

Transcript edited for clarity