WHAT ARE THE CHALLENGES IN ACHIEVING REMISSION?
Larry Culpepper, MD, MPH, discusses achieving treatment goals for patients with MDD.
More than half of patients with MDD fail to achieve symptom resolution with first-line therapies.1 Of those patients who achieve remission, over 90% have at least 1 residual symptom.2
The challenge of taking patients beyond partial response is further complicated by the fact that remission rates decrease with each subsequent line of therapy.1,3
Patients with residual symptoms are at an increased risk for relapse and other serious consequences, including3–5
Common residual symptoms seen in patients with MDD are depressed mood or diminished interest (anhedonia), cognitive problems, insomnia, and fatigue.2,6–8
Major depressive disorder presents a complex challenge—symptoms, progression, and response vary greatly from patient to patient.10 For a diagnosis of MDD according to the DSM-5, five or more symptoms must be present during the same 2-week period and represent a change from previous functioning. At least 1 of the 5 symptoms must be either depressed mood or loss of interest/pleasure.11
Major depressive disorder presents a complex challenge—symptoms, progression, and response vary greatly from patient to patient.10 For a diagnosis of MDD according to the DSM-5, 5 or more symptoms must be present during the same 2-week period and represent a change from previous functioning. At least 1 of the 5 symptoms must be either depressed mood or loss of interest/pleasure.11
With the heterogeneous nature of MDD, it is not surprising that numerous pathways and biologic processes have been implicated in the pathophysiology of depression. However, FDA-approved antidepressants primarily target monoamine pathways (serotonin, norepinephrine, and/or dopamine).13
References: 1. Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry. 2006;163(11):1905-1917. 2. Nierenberg AA, Husain MM, Trivedi MH, et al. Residual symptoms after remission of major depressive disorder with citalopram and risk of relapse: a STAR*D report. Psychol Med. 2010;40(1):41-50. 3. Practice guideline for the treatment of patients with major depressive disorder, third edition. American Psychiatric Association website. https://psychiatryonline.org/pb/assets/raw/sitewide/
practice_guidelines/guidelines/mdd.pdf. Published October 2010. Accessed July 14, 2017. 4. Judd LL, Schettler PJ, Rush AJ, Coryell WH, Fiedorowicz JG, Solomon DA. A new empirical definition of major depressive episode recovery and its positive impact on future course of illness. J Clin Psychiatry. 2016;77(8):1065-1073. 5. Miller IW, Keitner GI, Schatzberg AF, et al. The treatment of chronic depression, part 3: psychosocial functioning before and after treatment with sertraline or imipramine. J Clin Psychiatry. 1998;59(11):608-619. 6. Conradi HJ, Ormel J, de Jonge P. Symptom profiles of DSM-IV-defined remission, recovery, relapse, and recurrence of depression: the role of the core symptoms. Depress Anxiety. 2012;29(7):638-645. 7. Nierenberg AA, DeCecco LM. Definitions of antidepressant treatment response, remission, nonresponse, partial response, and other relevant outcomes: a focus on treatment-resistant depression. J Clin Psychiatry. 2001;62(suppl 16):5-9. 8. Shelton RC, Tomarken AJ. Can recovery from depression be achieved? Psychiatr Serv. 2001;52(11):1469-1478. 9. Paykel ES, Ramana R, Cooper Z, et al. Residual symptoms after partial remission: an important outcome in depression. Psychol Med. 1995;25(6):1171-1180. 10. Nelson JC, Pikalov A, Berman RM. Augmentation treatment in major depressive disorder: focus on aripiprazole. Neuropsychiatr Dis Treat. 2008;4(5):937‐948. 11. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013. 12. Zimmerman M, Ellison W, Young D, Chelminski I, Dalrymple K. How many different ways do patients meet the diagnostic criteria for major depressive disorder? Compr Psychiatry. 2015;56:29-34. 13. Dale E, Bang-Andersen B, Sánchez C. Emerging mechanisms and treatments for depression beyond SSRIs and SNRIs. Biochem Pharmacol. 2015;95(2):81-97. 14. Amitriptyline [prescribing information]. Princeton, NJ: Sandoz Inc; 2014. 15. Norpramin [prescribing information]. Bridgewater, NJ: sanofi-aventis US LLC; 2014. 16. Imipramine [prescribing information]. Fairfield, NJ: Excellium Pharmaceutical Inc; 2012. 17. Emsam [prescribing information]. Morgantown, WV: Somerset Pharmaceuticals Inc; 2015. 18. Zoloft [prescribing information]. New York, NY: Pfizer Inc; 2017. 19. Wellbutrin XL [prescribing information]. Bridgewater, NJ: Valeant Pharmaceuticals North America LLC; 2014. 20. Cymbalta [prescribing information]. Indianapolis, IN: Lilly USA LLC; 2016. 21. Viibryd [prescribing information]. Allergan USA Inc; 2011. 22. Seroquel [prescribing information]. Wilmington, DE: AstraZeneca Pharmaceuticals LP; 2016.