Closing Arguments

During their closing arguments, our debate participants summarize their respective thoughts from each of the three rounds to conclusively support their sides of this important debate.

Dr Charles Raison: Hi everyone. Thank you for joining us for the closing arguments of our Great Debates in Psychiatry series. Okay, Dr Banov, Dr Measom, this is your last chance to support your side for our viewers. So please, I'm going to ask each of you to give your closing argument that supports either a monotherapy or multimodal approach as the best strategy, in general, for the use of antidepressant modalities. So, Dr Banov, let's start with you. So, please go ahead and give us your closing argument.

Dr Michael Banov: Let me start by saying that there certainly is a part of me that wants to be simple and not harm my patients, and there's this emotional piece where I want to do something that's the cleanest for the patient, which is certainly a monotherapy approach. But let's go back to the old Dragnet show. For anybody, I guess, over the age of 50, just the facts. Here are the facts. The facts are we don't have evidence that multimodal therapies work necessarily faster or better. Yes, we do have evidence that non-responders down the road may benefit from certain augmentation agents, certainly like the atypicals. But let's just go back to the STAR*D trial. It's something that we always reference in many of the talks that I do, which says it doesn't matter what you did, whether you augmented or whether you switched, that patients did just as well, either one.

Dr Banov: And certainly, we know that multimodal treatments, or, I should say, polypharmacy, is going to patients at higher risk for non-compliance, higher risk for side effects, certainly more risk for serious adverse events. So, and the list goes on why we don't really wanna go down that road if we can avoid that by any stretch of the imagination. The other thing that I always thought was one of the most interesting findings in the STAR*D trial, I very rarely hear people talk about it, is after patients did not remit to their first go-round with escitalopram 40 milligrams, they ask patients, “Do you want to be switched or do you want to be augmented, or do you not really care and leave it up to the clinician?” Only 20 percent said they don't care.

Dr Banov: Patients have a strong opinion on what they want, so we need to ask our patients. And I find it very hard to believe that patients really want multimodal treatments out of the gate. There certainly may be some; there may be patients who have been on these kinds of medications before. Maybe they've had a good experience with polypharmacy, and in maybe, those patients, it's appropriate. But I think that some patients may be interested in polypharmacy, maybe more for the side effects of certain medications. Like I say, maybe a very sedating low-dose antipsychotic may provide relief of anxiety or insomnia, not necessarily helping their depression so much, but making them feel short-term, symptomatically better. But again, getting back to is there evidence to support coming out the gate with polypharmacy? I would say no. And if anything, there's evidence to the flip side, which is you're probably going to create more problems on many, many different levels. And let's not fall down the trap that some of the pharmaceutical companies may be trying to promote, which is the answer is a pill, and our pill's going to be better than your pill. And sometimes, that pill is adding several pills together, and I don't think that's what we want to communicate to our patients.

Dr Raison: Okay. Thank you, Dr Banov. Well said. Okay, Dr Measom. This is your closing argument. Please go ahead.

Dr Michael Measom: Well, you know, I'm fortunate to have the final word. So, not that it really matters that much. I think a lot; I have a lot of respect for everything Dr Banov has said. I think we agree on a lot of things. So, I would say that the world is changing. You know, we've been talking about monoamines for a long time, and now we have these rapid, more rapid-acting antidepressants, and to me, there's a shift and focusing more on symptoms. You know, we talk about STAR*D, but people don't talk about remission rates in STAR*D. So, I like to talk about response vs remission, and I like to see people back at 2 weeks, and I like to do measurement-based care. Part of what I do. So, and I agree with Dr Banov, you know, that person that's in the room with you matters, and listening to that person in the room and helping them achieve what they want. You know, I always talk about the Army's definition of recovery to be all that they can be and helping them get there. So, often, multimodal is the answer. I don't want people to have residual symptoms down the road because those residual symptoms can lead to recurrence of major depressive disorder. So, often, multimodal therapy is the answer.

Dr Raison: Okay, wonderful. So first, I want to thank my colleagues for a lively and informative debate. Lots to think about here. And thank you all for joining us. Be sure to tell us who you think won the overall debate by answering the poll questions you see on the screen. And take care of yourselves, and we will see you next time.