April 8, 2024
Written by
Alison McInnes, M.D., M.S.
Dear Colleagues,
As general psychiatrists, you are often the first point of contact for patients grappling with major depressive disorder (MDD). Your role is not just to treat but to guide your patients through the myriad of treatment options available beyond traditional oral antidepressants.
The traditional reliance on monoaminergic antidepressants has been a cornerstone of MDD treatment. However, recent findings, including those from the comprehensive STAR*D study—with over 4,000 patients—suggest that only about one-third of individuals achieve remission after multiple rounds of monoamine-based therapies.
A recent study by L. Alison McInnes MD, MS, and Tobias F Marton MD, PhD, sheds light on the limitations of traditional monoaminergic antidepressants and introduces a fresh perspective on alternative treatment modalities.
Key Takeaways from the Review:
The term TRD may contribute to misconceptions about the nature of depression and inadvertently stigmatize patients. It suggests a one-dimensional view of depression, centered on monoaminergic circuitry, which is increasingly seen as inadequate.
The label “TRD” implies that the patient has not responded adequately to at least two different antidepressant treatments, namely monaminergic antidepressants—which may represent just one subtype of depression, and may not even be the most common subtype. Regardless of the controversies surrounding the re-analyses for the Sequenced Treatment Alternatives for Depression data set, we know that the side-effect profile of serotonin-based drugs, including emotional numbing and weight gain, are intolerable for many patients.
The current review advocates for a shift in perspective away from a one-size-fits-all approach toward a moer personalized one. Consider depression as a spectrum of biotypes with distinct biological underpinnings, which could respond differently to various treatments like ketamine or esketamine, targeting the glutamatergic system.
Since the turn of this century, researchers and clinicians have been gathering experience with mechanistically distinct pharmacological and non-pharmacological treatment options for patients including brain stimulation, glutamate receptor modulators and psychedelic medicines.
Your patients are increasingly informed and may seek out these alternatives independently. It's imperative that you, as their trusted advisor, are well-versed in these options to guide them effectively.
Current Clinical Decision-Making
While these new treatment modalities have the potential to enhance patient outcomes, clinicians and patients currently lack a framework to guide their choices other than cost, feasibility, personal preference, and certain medical contraindications.The review highlights the need for a more nuanced approach, considering the individual's unique clinical profile and the comparative strengths and weaknesses of available treatments, including ECT, TMS, SGAs, esketamine, and ketamine infusion therapy (KIT).
Understanding which treatments align with specific patient profiles can significantly enhance treatment outcomes and patient satisfaction. Here's a detailed guide to help you make informed decisions based on individual patient characteristics:
Indications:
Contraindications:
Indications:
Contraindications:
Indications:
Contraindications:
Indications:
Contraindications:
Indications:
Contraindications:
Precision psychiatry will reshape your approach to treatment. You can advocate for tailored interventions based on individual patient profiles. Subscribe to the Psychiatry Tomorrow newsletter to stay informed about the latest research and developments. Understanding the the unique biological underpinnings of your patients' depression helps you guide them toward the most effective treatment.
Conclusion:
The study by McInnes and Marton encourages clinicians to look beyond traditional monoaminergic antidepressants and consider a broader array of treatment options for MDD. As precision psychiatry evolves, the future of depression treatment is poised to become more personalized, effective, and hopeful for patients struggling to find lasting relief. These innovations in treatment and treatment selection could relegate “treatment-resistant depression” to the history books.
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If you, or someone you know, is in crisis or needs immediate assistance, please call 911 immediately. To talk to someone now, please call the National Suicide Prevention Lifeline at 1-800-273-8255.
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