Round 1: When do you re-evaluate a patient's response to their current treatment?

In the first round of this debate, our participants tackle the issue of when to re-evaluate a patient’s response.

Dr Charles Raison: Okay, excellent. Now, before we begin, I'd like to introduce our participants in the debate today. So joining us are Dr Michael Banov and Dr Michael Measom. Dr Banov is going to support the side of monotherapy, and Dr Measom is going to take the side of multimodal therapy. Now, in addition, let me clarify for you that for the purposes of this debate, I am using, and we're going to use, the term multimodal; to mean, in more broadly, treatment with more than one medication at the same time vs monotherapy, which of course is where only one medication is used. And, you know, this is such an essential question. We know that many of our patients are on multiple medications, and there's two ways to look at it. One way to look at it is that people end up on multiple medications after they've not had an adequate response to a single medication.

Dr Raison: And then the question arises, do you get that much more benefit from adding additional agents? And then there's another question, which is also interesting and that has been debated in the scientific literature, which is whether or not, at least, some patients might benefit from actually starting their therapy with a couple of agents to try to sort of, maybe supercharge their response. So there are a number of issues here that are really fascinating. There's always the question of benefit vs side effects and tolerability. And we're going to try to cover all those issues today in our debate. Okay. Let's jump right into round one and begin by addressing our first debate topic, which is, at what point do you reevaluate a patient's response to their current treatment? So, Dr Banov, please go ahead with your opening argument.

Dr Michael Banov: Thanks a lot. I appreciate that introduction. A nice summary. You know, I hate to start with the word depends, but it kind of depends. It one of the big things; it depends on level of the patient's acuity. So, patients come to me that I'm worried about risk of hospitalization, of severe decompensation to the point of affecting maybe work-home situation, or, of course, worse, suicidal ideation and possibly following through with that. I'm going to see that patient a lot sooner, maybe within one week, two weeks. It also may depend on what the patient's needs are. If the patient this is their first go-round with getting treatment for depression, and they're anxious about it. They have a lot of questions; they may need more handholding. That's somebody that I'm going to probably see a lot sooner. Maybe again a week or two. Maybe a patient that's had a history of a lot of side effects—significant adverse events. Maybe medical issues that I'm worried about in combining with these various medications I may see sooner. But the patient who is a little more experienced with depression that maybe has been on medications before. Isn't their first go-round with it.

Dr Banov: Or maybe the level of acuity is much, much lower. I may see them back in 4 to 6 weeks. Because one thing is, I'm not necessarily expecting a dramatic response within 1 to 2 weeks. And furthermore, if I do bring them back sooner, I'm always a little worried that they may be expecting something to happen. Well, you saw me back in a week or 2, and I'm not really all that much better, so we must not be doing the right thing. So, that's kind of how I process. And it really depends on where the patient's at and meeting the patient in that place.

Dr Raison: Okay. Dr Measom, why don't you give us your opening statement?

Dr Michael Measom: Well, you know, when I was trained, my quick and dirty answer to your question is 2 weeks, just in general. Two weeks, right? So the change that occurs at 2 weeks is often predictive of long-term response. I get if somebody's suicidal, you need to see them sooner. I get if somebody has side effects, see them sooner. But, you know, my big thing here is that we're talking about response, and I want to focus on remission because I view this illness as a chronic, recurrent lethal illness. And I think we need to focus more on remission than response. So, any of my colleagues that will listen to me, I push them to do the follow-up in 2 weeks. And at the same time, I pushed them to do measurement-based care so that they know how their people are doing. I was a resident at the University of Wisconsin in Madison. I was told to see somebody at 1 month and wait for 3 months to see how they did. And that has totally changed for me. So, I just want to keep my responses short and sweet. My simple answer to your question is 2 weeks.

Dr Raison: Thank you, Dr Measom. He and I are laughing because, of course, I am at the University of Wisconsin, Madison. Okay. Dr Banov, this is a chance for you to give a briefer rebuttal or response to Dr Measom's thoughts.

Dr Banov: Well, I certainly agree with his comment about remission. We all want to strive for remission. The question is, if we're giving somebody a medication, and maybe that's their only treatment, are we expecting medications to do everything? Or is medication alone going to take him into remission? And then, are we going to see remission in 2 weeks? Unlikely. Medications just don't work that way. And if we typically dose some of these medicines at the therapeutic dose that may be required for a good response or remission, we run the risk of more side effects. And we know that many of our patients, if they take medicine for 2 or 3 days, have insomnia, agitation, sedation, increase in appetite; they're probably not going to take it. Because they're thinking, this is the way I'm going to feel the whole time. So, I think 2 weeks for some patients is right. But I think for many of our patients, it's unnecessary. And it's a setup for our patients to think, well, if you're seeing me back this soon and I'm not doing well, something's wrong.

Dr Raison: Okay. Interesting. Okay, Dr. Measom, now you get a chance to rebut his rebuttal. So, please go ahead.

Dr Measom: I'm going to rebut his rebuttal. Here we go. So, I have no problem with response, and I think response is a predictor of remission. And I think seeing, you know if you just want a simple answer in disease states—including major depressive disorder—the response at 2 weeks is highly predictive of long-term response, and even remission. I don't want to push the dose. I don't want to cause side effects. I want to help that person that's in the office with me, in front of me, and do what's right for that person. I think Dr Banov both agree on this.

Dr Raison: Yeah, well, definitely. Certainly. Okay, Dr Banov, this is your chance for closing statements. So, if we can just get a sort of gestalt of your argument so that we can leave our viewers with a clear sense of what you're suggesting, please go ahead.

Dr Banov: So, my general feeling is you have to meet the patient where they're at. And, as I mentioned earlier, patients who are highly acute, we're worried about hospitalization, worried about suicide, we're worried about rapid decompensation, of course, we're going to see them sooner. Although we may need to be thinking, is this somebody who maybe needs to be in a hospital? Oftentimes we're reluctant to put people in hospitals because maybe our experiences and patients' experiences haven't been that great in hospitals, but we have to look out for patient safety number one. I think that, again, setting patients up to come in too soon and expecting something dramatic to happen within those 1 or 2 weeks may be unrealistic. It may set patients up for expectations that just aren't practical. And part of the process for me is seeing you back in 4 to 6 weeks. And again, assuming issues, concerns about side effects, patients, questions, acuity, and all that are under control. It's telling the patients these things take time. It probably took you a while to get to this point where you came to see me, and it's going to take a while to get out of it. There's not a quick fix. We know that quick fixes are usually placebo responses for most of our patients. And quick fixes usually turn into quick declines pretty quickly.

Dr Raison: Okay. Dr Measom, your closing statement, please, sir.

Dr Measom: My closing statement. I'm going to go back to the original question about monotherapy vs multimodal therapy. And I'm a mechanism of action guy. The more mechanisms of action I can get, the more likely I am to get a response. And I want to measure that response earlier rather than later to predict long-term outcomes. So I'm a multimodal kind of guy. Thank you.

Dr Raison: Okay, thank you both. That's interesting! You know, there's always truth on both sides of a debate. This concludes round one of our Great Debate series. And be sure to tell us who you think won this round by answering the poll question that you see on your screen. And be sure to join us next time for round two, where we'll be discussing whether certain patient populations are more inclined towards monotherapy vs multimodal therapy.