Treatment of Episodic vs Chronic MDD

Andrew J Cutler, MD:Let’s shift gears here, Sagar, how would you treat a patient with either episodic episodes of depression or more chronic MDD [major depressive disorder]? Do you think about treating them differently?

Sagar V Parikh, MD, FRCPC: I definitely think if it’s recurrent, there are risk factors that are driving the recurrence. So that person needs a little bit more time to examine what might be contributing to the depression. It could be something as traditional as their negative self-talk, their low self-esteem and their depressive ruminations are so ingrained that a brief course of CBT [cognitive behavioral therapy] or a brief course of medication temporarily overcomes that, but then they revert to their profoundly negative self-appraisal routine and then that’s a setup for depression. I look for risk factors of recurrence. I do think about broader things like substance use and other things. We don’t forget about our old medical concerns about hypothyroidism, and so on. And then the factors that Greg has also mentioned about fostering resilience, like exercise. The literature on diet is surprisingly disappointing, I would say. The Mediterranean diet, it’s good for your heart. We hoped it would be good for your mood. It probably is a little bit, but there’s nothing very convincing that those kinds of dietary interventions are that helpful. Even the whole story about omega-3 supplementation was a little bit disappointing. So I’m less leaning towards that and more leaning towards looking at recurrence in terms of vulnerability factors. Obviously, then also thinking about the medication, could they be intermittently noncompliant? And why would they be intermittently noncompliant? Is it forgetfulness? Is it nasty adverse effects? Are there intervening side effects bothering them? Could it be a product of social media? Another blast comes out, antidepressants don’t work or whatever. And then they started having some doubts for a while, and then they stopped for a while, and then they start to feel unwell, and then they say, “I better get back on that.” So I tried to look at all the things that may be driving the recurrence.

Andrew J Cutler, MD: Sure. That really makes sense. Greg, that leads to a question I have. How would you treat a patient who’s relapsed after stopping their medication? Would you start them back on the same treatment or would you do something different?

Gregory Mattingly, MD: In some ways, that’s the rookie mistake, right, Andy? We’ve all seen that. Somebody stops their medicine, they relapse, and we say, “Oh, you have to go back on that same medicine” without asking why did you stop your medicine?

Andrew J Cutler, MD: Good point.

Gregory Mattingly, MD: Maybe I stopped my medicine because I was having adverse effects where I couldn’t be intimate with my partner, maybe I gained 20 pounds, maybe I felt emotionally blunted or flat, or I just didn’t feel like myself. Or as Sagar said, maybe it was an internalized stigma from something I’d seen or experienced where I beat up on myself for even needing to take a medicine, which I certainly deal with in my patients. So sometimes restarting a medicine can be the right answer, but sometimes it can be absolutely the wrong answer when you think about what are the right treatment choices for your patient. I do think one of the things we’re going to have to look at with this new treatment paradigm about intermittent use of a treatment, where we use an antidepressant, we only give it for 2 weeks, and then we take it again only as needed, which is what we did in the SHORELINE study. It means you’re going to do something Sagar talked about earlier. How do you measure if people are starting to relapse?

Andrew J Cutler, MD: Good point.

Gregory Mattingly, MD: I think measurement-based care is really important there. The use of a PHQ-9 [Patient Health Questionnaire-9], if you start feeling kind of funky, go online, fill this out and send it over to me. And if we see warning signs, we’ll get you in and we’ll talk about do we need to get you back on treatment. What’s going on with you? Is this an urgent need? Or is this just a sign that things are starting to tip in the wrong direction? I think measurement-based care—as we talk about the future of mental health care—is going to be really important.

Andrew J Cutler, MD: That’s a great point, Greg. Because ideally, you want to catch it before it turns into a big crisis. And we know that chronic and more severe depression is harder to treat than if you catch it earlier. So I think that’s an excellent point.

Transcript edited clarity