Evolving Management Strategies for Treatment-Resistant Depression - Episode 13
The appropriateness for initiating psychotherapy, either alone or in combination with other therapies, as frontline treatment for depression.
Steven Levine, MD: Let’s transition to discussing other treatment approaches for depression. Angelos, can you talk a little about first-line treatments? Do you tend to use psychotherapy as a first step in treatment? If so, do you use psychotherapy alone? Do you recommend it along with pharmacological treatment?
Angelos Halaris, MD, PhD, APA, ACNP, CINP: Excellent question. First, it all depends on the initial evaluation, which I like to make as thorough as possible. It’s certainly not a 20- to 30-minute initial assessment. That’s a nonstarter. It’s 45 to 60 minutes, possibly with a follow-up to complete the initial evaluation if necessary. I really want to make sure I understand what the patient is going through. What life circumstances do they have to cope with? What are the stressors in the patient’s life? What’s their history? All these are factors are very important and will guide me as I choose the treatment approach.
For the most part, I consider medication a top priority, but not exclusively. I am a staunch proponent of combination treatment with a psychotherapeutic modality concomitantly in the same session. It may just be a matter of supportive and educational therapy, providing a listening ear, showing empathy and compassion for what the patient is going through, and giving them hope where hope is appropriate without misleading them and giving false promises. I want to see them frequently at the beginning, not, “Here’s a prescription. Nice knowing you. Come back in 3 to 6 months.” That’s malpractice in my view.
Very often, I choose intensive psychotherapy, depending on the situation and what the patient is also struggling with. I had the fortune of being trained in some kinds of intensive dynamic psychotherapy, and I still apply it as appropriate. If the patient is interested in embarking on it, that could be as often as once a week or once every other week. At the very least, a monthly supportive therapy for the first 4 to 6 months is my modus operandi.
Lisa Harding, MD: My approach is a little different. I have an MA [medical assistant] who’s an E-RYT [Experienced Registered Yoga Teacher] 500-hour teacher. Before the infusion or insufflation, my patients all undergo an introduction to mindfulness meditation, and they have a 10-minute body scan, exercise, and meditative process before they undergo their procedure. This came out of papers that talked about psychotherapy. There’s this psychedelic thing that happens with ketamine that we really can’t quantify or tap into. We’re talking about this really unconventional approach with this new treatment. It leaves a lot of questions unanswered and ready to be answered.
If you have a major depressive disorder, it’s your first episode, and it’s mild, psychotherapy might be the thing. I primarily treat people with treatment-resistant depression, so we’re usually starting an intervention modality. I give patients some grace in starting psychotherapy because I don’t want somebody with a MADRS [Montgomery–Åsberg Depression Rating Scale] of 32 who’s struggling and has been failed by these conventional medications to then engage in psychotherapy, which is sometimes really taxing. I show them some grace. Sometime midway through the treatment, they start psychotherapy.
Transcript Edited for Clarity