Revisiting MDD Management in Primary Care

In " Revisiting MDD Management in Primary Care," our experts turn to what actually changed after the field's most humbling trial.

Dr. Alva describes STAR*D as a humbling mirror whose remission rates forced the field to recalibrate. He asks Dr. DeBattista what is typically prescribed in primary care now, and how much real-world gain comes from measurement-based care and faster switching rather than from new molecules.

Dr. DeBattista answers that SSRIs remain the most commonly prescribed class in primary care, not only in the United States but throughout the world. The starting dose is a therapeutic dose, they are relatively well tolerated, and they are comparatively safe in overdose. He adds that bupropion and duloxetine account for most of the remainder. He then delivers a candid verdict on the last two decades. He would like to think the standard of care changed after that study, but he does not believe it has. Response rates dropped substantially at each successive level, and there were no clear winners at any level. The hope had been to learn whether a patient who failed citalopram would do better on bupropion or buspirone. None of those comparisons panned out. He notes the only approved adjunctive options are second-generation antipsychotics and esketamine, neither of which the trial included.

Dr. DeBattista does credit the trial with one durable lesson. It showed there may be a limited window of response, and that a patient who does not respond in the first couple of trials becomes considerably harder to treat. He then turns to measurement, which he says has helped with screening and, more importantly, with prompting action. Clinicians are more likely to change course when they can see a limited response in front of them. But he closes on the gap. Only a small fraction of primary care clinicians, and even of practicing psychiatrists, use measurement routinely. He calls the movement in that direction real but slow.

Our next episode, "Partial Response in MDD: Optimize, Switch, Combine, or Augment," turns to the four levers available when a patient improves, but not enough.