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Is partial response good enough?
In order to help address partial response, many patients with MDD need more than an antidepressant alone
In the STAR*D study, >4 OUT OF 5 patients continued to have a partial response after their second antidepressant treatment1,a
Despite evidence supporting appropriate use, adjunctive atypical antipsychotics were prescribed late in the MDD treatment journey2
A chart review study showed that a patient may undergo ~5 TREATMENT CHANGES before being prescribed an adjunctive atypical antipsychotic2
According to a meta-analysis,
The chance of response (defined as a 50% improvement from baseline to endpoint on either the MÅDRS or HAM-D17) increased by 68% in patients treated with adjunctive atypical antipsychotics vs antidepressant treatments alone (odds ratio=1.68)3,b
aAs demonstrated in almost 3700 adult patients with MDD who were prescribed antidepressants. In the STAR*D study, partial response was defined as a less-than-50% reduction from treatment step entry in Quick Inventory of Depressive Symptomatology Self-Report score at 12-14 weeks. The patient sample received successive acute treatment steps: 3671 patients entered at Step 1; 1439 patients continued at Step 2; 390 patients proceeded to Step 3; 123 patients advanced through all 4 steps. After SSRI monotherapy in Step 1, treatment options included switching medications or augmentation with either medication or cognitive therapy. Adjunctive atypical antipsychotics were not included at any step. Patients who either did not achieve response with a treatment or were unable to tolerate a treatment were encouraged to move to the next step.1
bIn a meta-analysis, response was defined as a 50% improvement from baseline to endpoint on either the MÅDRS or HAM-D17. Meta-analysis included 17 randomized trials with 3807 patients (duration range: 4-12 weeks) comparing adjunctive antipsychotic treatment to SSRI/SNRI treatment in adult patients (age range: 18-65 years) with MDD. There was a 68% greater chance of response from the antidepressant + adjunctive antipsychotic group vs the antidepressant + placebo group.3
HAM-D17, 17-item Hamilton Depression Rating Scale; MÅDRS, Montgomery-Åsberg Depression Rating Scale; MDD, major depressive disorder; SNRI, serotonin and norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; STAR*D, Sequenced Treatment Alternatives to Relieve Depression.
Watch Dr. Jain discuss the prevalence of partial response in MDD and considerations for addressing it
“I’m on an antidepressant, but I still have little interest or desire in doing things.”
“My depression is not getting better.”
“I am on a treatment for depression, but I am still feeling sad.”
Dr. Jain: Do you see patients like these in your practice?
Dr. Jain: Major depressive disorder, or MDD, can be overwhelming for your patients and challenging for clinicians—especially when our patients continue to experience symptoms.
Dr. Jain: My name is Dr. Rakesh Jain, and I am a Clinical Professor in the Department of Psychiatry and Behavioral Sciences at Texas Tech University School of Medicine.
This video was created by Otsuka America Pharmaceutical, Inc. and Lundbeck for healthcare professionals looking for guidance when patients with MDD have symptoms that are not adequately treated with antidepressant medications.
We’ll review the prevalence of inadequate response to antidepressant therapy in patients with MDD. We will discuss recommended treatment options, and explore current utilization of atypical antipsychotics as adjunctive treatment for these patients.
Many of us have had patients with MDD who don’t respond well to an initial course of antidepressant treatment, but how common is this problem?
The STAR*D trial evaluated outcomes in patients with MDD across successive steps of treatment.
Dr. Jain in voiceover: In this large study involving a broadly representative population of outpatients, at least 50% of patients with MDD did not achieve an adequate response after initial treatment with an SSRI.
Results of that classic study, published more than 10 years ago, have been confirmed in several meta-analyses. Together, these studies demonstrate that there is no one-size-fits-all approach for MDD.
Dr. Jain in voiceover: If we extrapolate from the STAR*D study to the overall US population, we can estimate that as many as 8.2 million adults in the United States may currently have an inadequate response to their antidepressant.
So, given that estimated prevalence, odds are that you may have patients with MDD in your practice who demonstrate inadequate response as well.
Dr. Jain in voiceover: What is the best approach to treat patients with MDD experiencing an inadequate treatment response? Let’s look at the professional guidelines.
The American Psychiatric Association, the leading authority for MDD treatment guidelines, endorses four treatment options, which may be used concurrently: First, optimize medication dose as tolerated. Second, augment pharmacologic therapy with depression-focused psychotherapy, an option at any time during treatment. Third, switch to a different monotherapy of the same or different pharmacologic class, and fourth, augment with antidepressant pharmacotherapy, including an atypical antipsychotic.
Dr. Jain: At least two meta-analyses were recently published comparing outcomes in patients with MDD who had an inadequate response and who were then treated with an antidepressant alone or an antidepressant plus an atypical antipsychotic.
Both showed adjunctive use of atypical antipsychotics significantly increased response rates versus antidepressant alone. This provides further support for considering an atypical antipsychotic when adjunctive therapy is indicated.
Dr. Jain in voiceover: However, although we see that patients can potentially benefit from adjunctive treatment, one study suggested that fewer than 10% of patients with MDD who received a change in their treatment received an atypical antipsychotic. What could be the reasons for this discrepancy?
Dr. Jain: Let’s look at a survey that asked for reasons why physicians did or did not prescribe an atypical antipsychotic for their patients with MDD who had an inadequate response to treatment.
In a recent survey, physicians in the United States and Europe were asked to document the reasons behind their treatment decisions for 10 consecutive adults with MDD who had an inadequate response to antidepressant therapy for whom they had considered or made a treatment change.
The most common reason for not prescribing an adjunctive atypical antipsychotic, or not prescribing one earlier, was a preference to wait to see if symptoms improved. Other common reasons were that the patient’s response to antidepressant therapy was adequate, their symptoms were not severe enough for an atypical antipsychotic, and the physician had concerns about tolerability or safety.
The most common reasons physicians reported that they did prescribe an adjunctive atypical antipsychotic for individuals with MDD with an inadequate response to their antidepressant were: that they were looking for efficacy and symptom control in addition to the patient's current treatment, specific drug features, as well as the patient's disease and their treatment response history.
Dr. Jain in voiceover: What is your approach when your patients face an inadequate response to antidepressant treatment?
Dr. Jain: It is my sincere hope that you consider this information when you’re developing treatment strategies that may improve symptoms for your patients with MDD for whom monotherapy is not enough.
Thank you.
Dr. Rakesh Jain, MD, MPH
Clinical Professor
Department of Psychiatry
Texas Tech University School of Medicine
Austin, Texas
The presenter is a paid consultant of Otsuka America Pharmaceutical, Inc. and Lundbeck.
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