Tailoring Treatments for Patients With MDD


Greg Mattingly, MD, and Jeremey Schreiber, MSN, PMHNP-BC, discuss navigating the challenge of a “one size fits all approach” when treating and identifying the specific needs of patients with major depressive disorder (MDD).

Greg Mattingly, MD: Let me ask you a question. This is maybe a little controversial, but I think we all have habits. OK? We maybe have habits that we learned when we were training. Maybe habits we’ve developed in our practice and maybe 10, 15, 20 years ago that was a really good habit, but maybe there’s better habits now. So this kind of one-size-fits-all [habit]. No matter which patient walks through my door, I’ve got my favorite tool. I’m going to give them this SSRI [selective serotonin reuptake inhibitor] or I’m going to give them that or this. What do you think about one-size-fits-all versus [when] we talk about how do we individualize treatment so we don’t wind up just doing the same habit with everybody?

Jeremy Schreiber, MSN, PMHNP-BC: I think the one-size-fits-all is definitely not something that we should do. I had a student a couple years back and we were training, and he ended up coming to work at the same practice where I work and I ended up giving him, I don’t want to say giving, but transitioning some patients to him to help build his caseload. He came down the hall to me one day and he said, “You know what, Jeremy? You use a lot of different medicines. Some of these medicines, I don’t even know what these are!”I said, “Oh my goodness, you should know what all of these medicines are.” We have more than 1 tool in our toolbox, but I think you’re absolutely right. Do I have medicines that I like that I think will tend to be more reliable than other medications? Absolutely. At the same time, we have to tailor our treatments. Let’s say they have depression with insomnia, I may be more likely to prescribe medications that have a little bit more of a sedating component. Or if a patient comes in my office and says to me, “Oh Jeremy, I can’t gain weight,” which is a frequent thing that patients will say. I’ll say, “OK, there’s some medicines that I like that aren’t going to be, or are common weight gainers.”Maybe somebody has a depression where they have more anorexia and appetite decrease and they need something to help them gain weight. I may choose those agents. A lot of times the nuance of treating depression is looking for the nuance in presentation and tailoring the treatments for our patients. We may do this more commonly in psychiatry than some of our colleagues in other fields of medicine and not saying anything bad, it’s just this is the specialty that I’m in and this is where you also live as well, Greg. I don’t know what your thoughts are in the matter. Do you think that we in psychiatry have our favorites?

Greg Mattingly, MD: Of course we do. I’ll echo a story that’s very similar to you. We just had a chief resident come join us about a year ago. Former chief resident in psychiatry from one of our top universities. I said, “What’s the hardest part of being in our clinical practice? Is it that we combine seeing patients and some research and we see people across the age range and all that kind of stuff and the pace of practice.” He says, “No. The hardest thing is all the medicines you use. We never used when I was training.”I say, “Really?” He says, ‘You use little bits of everything and you have certain patterns and certain habits and certain ones you use, but you’re never really staying in that habit. You’re always looking, and asking yourself should I do something different?” So I think mixing it up saying what are the unmet needs? What are the residual symptoms? Once again, mental health vital statistics are needed. If I know your levels of depression, if I know your levels of anxiety, if I know your levels of cognitive issues, it changes the way I’m mixing and matching my medicines and blending them together.

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