Optimizing Engagement with Patients with Major Depressive Disorders: Essential Components for Success
These are the five things that I hold dear as key ingredients to a successful engagement when diagnosing and treating a patient with major depressive disorder.
1. Your reaction when eliciting symptoms. The most appropriate reaction is to share with the patient that their symptoms are common, that they’re treatable, and that you totally have a handle and an understanding on the situation. That will reassure the patient that they’re in good hands, that what they’re experiencing is something that’s very common and treatable, will inflate the placebo response, and help with the doctor/patient rapport.
2. Find a way to measure symptoms of depression. Personally, I use a clinician rated scale (the Hamilton scale), but most people use a patient rated scale. There are two reasons why that’s important.
- You’ll have an understanding of how symptoms fluctuate over time.
- It educates the patient around what the goal of treatment is.
Many times, almost always, if you let patients share their experience with depression, they’re going to focus on psychosocial issues like how depression is making their life difficult, how depression is making their work difficult. It’s critically important to shift that discussion from the external realm to the internal realm, from psychosocial to symptom-based, and that is a very important thing to be able to do during the course of treatment.
3. Don’t linger on a specific dose. Always try to optimize the dose. For the average patient, I optimize the dose every two weeks. If someone is very ill, very symptomatic, I even optimize the dose every week in the beginning. And that, of course, takes into consideration tolerability. Tolerability aside, you really want to be doing something every one to two weeks, and that’s in the benefit of the patient so that they cannot be symptomatic for a longer period of time.
4. Avoid tunnel vision with switching. Predominantly, clinicians use switching one antidepressant to another to get patients better. The Star*D study has shown us that after the second switch, switching becomes futile. Clearly, you’re going to start with monotherapy, maybe you’ll switch if that doesn’t work. After that, you really want to combine and augment. That’s where the majority of the data is, the strength of the data telling us what to do if antidepressants don’t work alone.
5. Start psychotherapy as early as possible. That is going to add resilience so that when the patient eventually reaches remission, they don’t roll back into being symptomatic.
Note that sometimes the referral can be too early. Sometimes, when patients are so symptomatic, if you refer them to therapy, they’re unable to engage and then they get discouraged and they don’t reengage in the process. For the most symptomatic of patients, you want to wait a little bit before referring them to therapy, and often therapists will give you an idea. They’ll call me and say, “George, this is something I can definitely help with. But see if you can remove some of the symptoms with medications first before I engage. Because right now they’re just going to be spinning their wheels.”
George Papakostas, MD is a psychiatrist at Massachusetts General Hospital and an assistant professor at Harvard Medical School.
This is Five Minute Pearls for The Journal of Clinical Psychiatry, in partnership with the American Society of Clinical Psychopharmacology.
