Major Depressive Disorder: Assessing Response to Therapy and Helping Patients Reach Remission

Major Depressive Disorder: Assessing Response to Therapy and Helping Patients Reach Remission Posted By:
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Best Practice for Assessing Response to MDD Therapy and Helping Patients Reach Remission
As a healthcare professional (HCP), it's important that part of our process is to evaluate the patient’s response to therapy. When patients say, “Hey, you know, I'm really feeling better. My mood is better, but I still don't feel like myself,” it's important for us to not just focus on the fact that their mood is better. We should not wave the remission banner too soon and continue to assess and treat as we see the patient in follow-up. We need to look for things like resistance to treatment. Sometimes the patient still has leftover symptoms of depression indicating an inadequate response, while other times those thoughts are adverse effects of the medication.

While patients can have some improvement in mood, sometimes we see a disconnect, with cognitive dysfunction occurring or even emotional blunting. When you start asking questions about the things that they can do, and the things that they still feel that they are unable to do often, this is where you see issues. They may mention not being able to complete daily tasks. They may report not being able to organize their calendar, or get to appointments on time, or meet deadlines at work or for home, like taking children to school, etc. So those cognitive issues really need to be discussed with the patient and then evaluated and obviously, as HCPs, we want to further treat those so that the patient can get to full remission.

One of the things I always tell HCPs is to make sure you know colleagues you can call for assistance when you need help with a case. When you're looking at that patient who you're not sure is completely in remission and you're not sure which direction to go, you want to have some assessment strategies to figure out what might be going on. Is there emotional blunting? Is there cognitive dysfunction? Are there other adverse effects that the patient is concerned about? Has the patient suddenly developed some suicidality that wasn't there before?

Like anything else in primary care, we want to get patients to full remission, we don't treat hypertension or diabetes to just good enough. We try to treat to our goal numbers and in mental healthcare, we want to be doing that as well. If we’re monitoring a PHQ-9, a BDI, or an anxiety inventory, we want to try to get to the patient being actually in remission.

Optimizing Communication With Patients and Employing Motivational Interviewing
As a provider, I find it helpful to talk to the patient about the importance of good communication and I always ask them to reach out to me and let me know when things might be changing because they might be experiencing changes in cognitive function or changes with an adverse effect. I don't want them to assume that some changes are a normal part of depression or depression treatment. While it's important for the patient to be able to reach out, it's also important for the HCP to employ motivational interviewing techniques with a lot of open-ended questions that will allow the patient to further verbalize what they are feeling and what is going on. This way, you will have additional assessment information to make decisions.

Strategies to Facilitate Ready and Affordable Patient Access to Optimal MDD Therapy
As we look at how we treat patients, a lot of times we follow guidelines that recommend to always start a particular medication first and then if that fails, try something else. Thereafter, we get to a place where we need to start a medication that is going to require a prior authorization or a peer review to provide rationale for why we are considering something different. This is important because we want to make sure that we are using the best medication to treat our patients. So often I like to put a lot of good clinical decision-making in my notes explaining what I've tried, what hasn't worked, what follow-up I have done, and sometimes even genetic testing can help guide what medications would work better. If you are submitting a prior authorization to an insurance company, you’ll want to include lab work that has been done, your note, and a letter from you explaining your treatment process before requesting the authorization.

Although genetic testing is still in its infancy and we're still looking closely at the data as they come out, it can sometimes be a helpful tool to determine what a patient might better respond to than what you’ve been trying. I know that patients sometimes get nervous about this. It is a simple cheek swab, so I try to reassure patients about the procedure. The key is looking at how you can write a prior authorization or a peer-to-peer letter so that you can make sure that your patient is able to access this form of diagnostic testing. I think it is something for us as HCPs to continue to assess and look at as it evolves as again a strategy that we can use to assist patients.


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Filed under: Psychiatry , NPs & PAs

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