Despite the availability of a range of interventions to address depressive symptoms, a substantial number of patients do not fully engage in treatment or show an adequate response to antidepressant therapies. Studies have shown that approximately 10% to 15% of patients with depression do not return for treatment following initial evaluation, and 50% of those who do engage in treatment prematurely discontinue antidepressant medications within 6 months.1,2 In addition, one-third of treated patients never achieve remission despite exposure to various types and levels of interventions.1
While these findings demonstrate some of the main challenges that significantly influence outcomes in depression treatment, there are no systematic consensus psychosocial approaches to target these issues. To that end, the authors of a recent paper published online in the American Journal of Psychiatry recommend the use of a patient-centered medical management model that includes psychoeducational, interpersonal, cognitive, behavioral, and dynamic components.1
This approach “deﬁnes and provides alternative means to address the four essential clinical tasks … in order to optimize outcomes when medication or neurostimulation is the chosen treatment,” they wrote. “Each treatment task is essential to optimizing the chances of recovery, and each is typically addressed in a stepwise manner, informed by the patient’s speciﬁc needs.”1
For example, if a patient demonstrates difficulty with adherence the patient and provider may discuss options and decide to try a reminder system. If that proves ineffective, the clinician might employ a cognitive approach to elicit and clarify any misconceptions the patient may have regarding their medication or their beliefs or feelings about taking it.
These 4 essential treatment tasks are summarized below, along with a few examples of methods that may be used to address each task, depending on the patient’s context and the clinician’s judgment.
Patient engagement, retention, and optimization of treatment adherence. Establish collaboration and alliance with your patient, use motivational interviewing techniques, discuss available options to manage adverse events and agree on how results should be measured.
Optimized control of symptoms and side effects via medication adjustments, using measurement-based care procedures. Discuss pros and cons of treatment options as part of shared decision making, monitor treatment progress with rating scales, switch or augment therapies if needed, and/or seek a second opinion.
Restore daily functioning and quality of life. Discuss and prioritize your patient’s needs regarding relationship issues and health goals; recommend marital, occupational, or interpersonal therapy if indicated; treat comorbidities such as general medical conditions and substance abuse disorders.
Relapse prevention or mitigation. Help patients learn to recognize prodromal symptoms, recommend resilience training and stress management, increase protective factors and reduce risk factors.
“Systematically addressing each task with methods speciﬁcally chosen for or tailored to each patient … should make recovery more likely and resource utilization more cost-effective,” the authors concluded. “Psychiatrists should be trained and prepared to deliver these methods themselves, as well as to oversee their delivery by the relevant treatment team members.”1
For additional discussion regarding patient-centered medical management for depression, Psychiatry Advisor spoke with co-author Michael E. Thase, MD, professor of psychiatry and director of the Mood and Anxiety Program at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia.
Psychiatry Advisor: Why is there a need for this patient-centered medical management approach for depression?
Dr Thase: Many people want to be more involved in their treatment, to play an active role in decision making, and to be fully engaged in the ongoing process of monitoring outcomes, dealing with adverse events, and — if the first treatment doesn’t work — weighing the pros and cons of various alternatives. The patient-centered model of treatment simply incorporates these ideals into contemporary approaches to ambulatory care in both primary and specialty care settings.
Psychiatry Advisor: Can you briefly describe what this would look like in practice?
Dr Thase: In practice, this may not look much different than what some skilled clinicians do already. Of note, at key points in the treatment process such as conveying the likely diagnosis, including the degree of certainty and other possible diagnoses and presenting recommendations for treatment, the clinician will explicitly elicit questions, openly discuss skepticism, and present options, typically ranking each by preference and quickly summarizing the pros and cons.
For example: “For your level of depression, I usually recommend beginning treatment with one of the selective serotonin reuptake inhibitors because of their track record, safety, and low cost. There are a couple of other first-line medications that have different side effect profiles and possible strengths, and I wonder if you have any thoughts about which treatment might best match your preferences.”
Psychiatry Advisor: What are other treatment implications for clinicians? For example, how can they begin to incorporate elements of this approach into their practice?
Dr Thase: Part of the fun of medical practice is learning to improve our skills and grow professionally. Trying out new strategies and approaches is one way to stay “fresh” professionally and may even improve burnout. It would be nice if expert videotapes were available online to facilitate this kind of learning. Maybe we can brainstorm about ways that the American Psychiatric Association and organizations, such as the Depression and Bipolar Support Alliance, can help to develop such materials.
Psychiatry Advisor: What should be the focus of future studies on this topic?
Dr Thase: The methods can be operationalized, and the hypothesis of greatest interest that a patient-centered care strategy will reduce attrition, improve medication adherence, increase symptom improvement, and enhance patient satisfaction with care can be tested. So, now all we need is the funding to support such a study that includes a comparison group receiving usual care.
Currently, the National Institute of Mental Health supports larger-scale clinical trials that focus on implementation and dissemination of innovative strategies. Alternatively, other federal agencies (such as the Agency for Healthcare Research and Quality), foundations that support behavioral healthcare research, and the pharmaceutical industry might be interested in this kind of pragmatic study.
1. Rush AJ, Thase ME. Improving depression outcome by patient-centered medical management [published online September 17, 2018]. Am J Psychiatry. doi: 10.1176/appi.ajp.2018.18040398
2. Sansone RA, Sansone LA. Antidepressant adherence: are patients taking their medications? Innov Clin Neurosci. 2012;9(5-6):41-46.