MDD Side Effect Profiles: Counseling, Adherence, and Suicidality Monitoring

In "MDD Side Effect Profiles: Counseling, Adherence, and Suicidality Monitoring," the panel explores how pharmacology predicts the conversation a prescriber needs to have.

Dr. Alva observes that side effects track pharmacology so closely they can almost be predicted from a receptor binding profile. He asks Dr. Clayton how she reasons about mechanism with patients.

Dr. Clayton says she avoids duplicative drugs and offers two options at the outset. She explains what each drug does and where each would help, then lets the patient choose. Occasionally someone is too depressed to decide, but usually people do choose. If the first is not tolerated or does not work, they move to the second, then to a new mechanism. Her reasoning is blunt. Fewer than 50% of people respond to monoamine-active antidepressants, which means something else is driving the depression. On tolerability, she says everything causes dizziness and nausea is often transient if patients understand they can get through it. She describes patients who say nothing has ever worked, until the history reveals one or two doses and a likely anxiety-related reaction. She uses pharmacogenomic testing to show them they metabolize normally, then asks for a month of commitment.

Dr. Alva turns to Dr. Oyedeji on which effects belong in the first conversation. She tells patients no side-effect-free option exists, and notes they have already researched thousands of possibilities. She keeps safety first, watches for mood shifts in adolescents given the black box warning, and empowers patients to report anything off kilter. She refuses to ignore the metabolic. Her patients skew female, and weight gain or sexual dysfunction is serious when they are already at a deficit, driving non-adherence.

Asked how often to assess suicidality, Dr. Shirikjian says every visit, documented, regardless of age. She gathers collateral, and notes esketamine carries a suicidality indication requiring closer contact. For oral agents where the next visit may be months away, her patients text her.

The next episode in this series, " Revisiting MDD Management in Primary Care," features Dr. DeBattista revisiting a landmark trial that humbled the field.