Solving Clinical Challenges in Major Depression
Solving Clinical Challenges in Major Depression
Dr. Thase is with the Department of Psychiatry, Perelman School of Medicine of the University of Pennsylvania and the Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104
Editor’s Note: We are pleased to present this brief summary, based on Dr Thase’s presentation, “Solving Clinical Challenges in Major Depression” at the 2017 Psychiatric Congress. That presentation focused on answering attendees' questions about challenging patients and on thorny clinical issues that arise during the case of depressed patients. A summary of key points of the Q&A follows.
Is it grief or depression?
A number of cases are presented that illustrate changes in diagnosis and practice ushered in following the publication of DSM-5 in 2013. The first describes a 60-year-old African American woman who was brought in for treatment by her adult children about 7 months after the death of her husband of more than 30 years. The patient had a history of 2 major depressive episodes (MDEs) and had responded to a trial of paroxetine some years ago, but stated “this [depressive episode] feels different—I don’t want to be medicated—why won’t my kids just let me alone to grieve?”
Of course, the relevant change in DSM-5 reflects the fact that it is neither justified nor helpful to try to differentiate grief from depression when the individual presents with a full depressive syndrome (a recurrent episode of MDD in this case). Specifically, studies have shown that depressive episodes of bereaved individuals are very similar to those experiencing other kinds of stressful life events.
In this case, what was helpful was to accept our patient’s sustained, unresolved grief as the primary initial focus of treatment utilizing interpersonal psychotherapy (IPT) as the first-line intervention. That said, clinical features that were not evident in this case that might have “pushed” the decision to recommend pharmacotherapy at the outset of the treatment episode include suicidality, psychosis, and disability/incapacity. Our challenging patient appreciated the chance to do grief work, although her depressive episode, which included fairly pervasive anhedonia, did not remit with IPT. She benefitted from the addition of escitalopram (final dose: 20 mg/d) and is now recovered, with the focus of IPT eventually shifting from grief to role transition.
Distinguishing between MDD and depressive episodes
Other cases highlighted our daily challenges distinguishing between “unipolar” depression (ie, MDD) and depressive episodes that more accurately are conceptualized falling with a spectrum of bipolarity. It is now clear that the actual incidence of bipolar II disorder is quite fluid based on the number of signs/symptoms and the duration of symptoms that are required as the threshold for diagnosis. For example, in the classic study of Angst and colleagues,1 the proportion of depressive episodes that met threshold for diagnosis for bipolar II varied more than 5-fold (ie, from as low as 2% to as high as 11%) based on the criteria. There are thus a lot of people—perhaps up to one-half of all those who seek treatment for MDD—who technically do not meet relatively strict criteria for bipolar II disorder who have a number of subthreshold features of the disorder.
Arguably the most intriguing change for the depressive disorders ushered in by DSM-5 was the addition of the “. . . with mixed features” specifier for MDEs, which can be applied to describe “unipolar” as well as bipolar depressive episodes. Defined by both negative (ie, does not meet criteria for hypomania) and positive (at least 3 symptoms of the other “pole” of illness) features, use of the mixed features specifier is hoped to help clinicians identify patients who are at greater risk to switch from MDD to bipolar disorder over time, as well as patients who may benefit from use of mood stabilizers—either alone or in combination with antidepressants.2
Although DSM-5 criteria for the “with mixed features” specifier can be used verbatim to make the diagnosis, practice may be facilitated by the use of self-report scales for both diagnosis and monitoring of outcomes. In this regard, the scale by Zimmerman and colleagues3—CUDOS-M—appears to be “shelf-ready” and preliminary studies show sound psychometric characteristics. It does, however, remain to be seen if the routine screening for and monitoring of mixed features can reliably improve outcomes in everyday practice. Results of the first prospective study of treatment of MDD with mixed features, a placebo-controlled study of lurasidone 20 to 60 mg daily, showed that substantial clinical benefits could be achieved without the use of antidepressants.4
With respect to pharmacotherapy of depressive disorders, there were several questions about differentiating the role(s) of the more recently introduced antidepressants from the generically available first-line therapies, as well as questions reflecting abiding concerns about the widespread use of second generation antipsychotics (SGAs) relatively early in treatment algorithms. I think it is fair to say that vilazodone and vortioxetine are not simply “me too” drugs and both offer some potentially unique properties compared with FDA-approved SSRIs.
This is also true for levomilnacipran, as its racemic ancestor (milnacipran) was not approved for treatment of depression in the US. However, their potential value as first-line medications is largely blocked by formulary pricing decisions that tend to place these medications in second, third, or even lower tiers.
No session on MDD is complete without a number of cases and a slew of questions about treatment-resistant depression. There is little uncertainty about the efficacy of SGAs when used as adjuncts to otherwise ineffective antidepressants: multiple positive placebo-controlled studies have established the efficacy of risperidone, aripiprazole, olanzapine, quetiapine, and brexpiprazole for this indication. However, real questions persist about cost-effectiveness and the best practices to mitigate risks of weight gain and other adverse metabolic effects and to help ensure patient safety during longer-term use of SGAs.5