Round 2: Does the treatment approach influence the speed of recovery from depression?

In the second round of this engaging debate, our participants discuss whether the treatment approach influences the speed of recovery from depression.

Transcript:

Brooke Kempf, MSN, PMHNP-BC: Hello, everyone, and welcome back to our Great Debates in Psychiatry series, brought to you by Psych Congress Network. We are now going to get started with round two of this debate, where we're going to be discussing how the treatment approach affects the speed of recovery from depression. So, Tina, we're going to get started with you. Could you give us your opening argument, please?

Tina Matthews-Hayes, DNP, FNP, PMHNP: Absolutely. So, I'd like to first start out by talking about STAR*D, which I feel like we talk about a lot in any discussion of major depression disorder. The study is almost 2 decades old, but we still reference it all of the time. But I'd like to focus a little bit on the fact that I believe we look at STAR*D, and we say that only 35 to 45% of patients reach remission within, you know, in the first line of treatment. And I respect that, you know. I wish the numbers were better, and I wish I could make them better. However, I don't negate that almost 45% of patients that could reach remission with a first-line treatment of an antidepressant. So that's said, I think we also need to look at the fact that there are new meds in the pipeline.

We have new meds that are novel, new mechanisms of actions that are very new to the market, or I'm sorry, very new to us as prescribers and, hopefully, very new to EHRs soon, which could, you know, according to research, provide remission data in much earlier timeframes than the traditional medications that we'd previously been using. That is important because, you know, again, in my experience, I feel like that if I can lift that depression, even just a little bit. If I can increase that motivation, just a little bit again, you know, getting that patient to the end goal of, you know, mixing the lifestyle modifications with the medication management and yielding the best results of some remission scores and depression is, that's usually the best outcome if I can get some a little bit quicker of a buy-in.

So, I'm very excited to see what those new medications are that we'll have access to. When my patients come in, the biggest thing that they complain about is that lack of motivation and their inability to sleep. Those are the biggest complaints I hear. So, again when, if I'm going to treat a patient, if I can treat that sleep, if I could treat that motivation, sometimes, like I said, I can then talk them into, okay, so, you know, “Are you getting out, are you getting any exercise?” What, “Are you going to therapy?” You know, “Let's get you rescheduled with your therapist.” It's really hard to sit on a couch with a therapist for an hour and talk when, you know, when you, when I couldn't even get you to get off your couch and stop watching Netflix. Right? It is just they don't; there's no engagement when you're feeling that low. So, with the utilization of some of the newer medications, hopefully we can, we can change that.

Brooke Kempf: I feel like you're speaking to my heart there, Tina.

Tina Matthews-Hayes: Well, it's one of the other things I say to a lot of my providers is, you know, yes, I agree with therapy. We need to have them in therapy. But if I can't get, if they haven't showered in 2 weeks, how can I get them to the therapist?

Brooke Kempf: Great points. Desiree, I'd love to hear your opening argument.

Desiree Matthews, PMHMP-BC: Incorporating holistic measures, like changes in diet and exercise, can be implemented immediately without the need for referrals or prior authorizations. Like Tina, and I'm sure Brooke, (I’m) very excited about these new and novel rapid-acting treatments for depression. But again, time is crucial when it comes to treating patients. It may take time to get patients' prior authorization status completed, and we still may see barriers in terms of access due to cost or even finding a provider that may be able to provide these new and novel treatments. When we consider exercise, we know that exercise has been shown to provide immediate benefits, improving both mood and promoting feelings of mastery. One study published in Psychology of Sports and Exercise found that exercise led to improvements in depressed mood states and anhedonia for up to 75 minutes post-exercise in adults with major depressive disorder. Prescribing exercise can be a very valuable addition to treatment, especially considering the, again, the potential delays and the side effects associated with medication-based approaches. I know for many of my patients they'll start a medication, and they will come back or call a week or two after letting me know that they had stopped their medication because of adverse side effects. And unfortunately, we're back to square one with trial and error with new medications. By embracing holistic measures, we can enhance treatment and potentially reduce the impact of depressive symptoms on patients' lives.

Brooke Kempf: Excellent information. I like how you said to prescribe exercise. Because I found I've literally had to write it on a prescription pad before as a recommendation. So, thank you again for your information. Tina, I'd love to hear your rebuttal.

Tina Matthews-Hayes: Again, you know, I would completely agree, my ‘but,’ because there's always a but in a debate, right? My ‘but’ would be I would've hoped in the perfect world when that patient started demonstrating some symptoms of mild depression; I would've hoped that at that point, we would have been talking about diet, exercise, and making changes. You know, maybe at the primary care level or when the depression wasn't as significant. So, in the perfect world, diet and exercise would work every single time, and the patients would feel better, and they would not need medications. However, what we know is there's a direct correlation between obesity and depression. We know that. We acknowledge that the signs is (are) there, but we also know that there's a direct correlation between obesity and socioeconomic levels and income levels.
And the harsh reality is that eating healthy in the United States is expensive. So, in 2020, 20.6% of Americans actually reported they had food disparities, or they struggled significantly with food insecurity. Food insecurity is directly correlated to obesity, which is directly correlated to depression. So, it's like we have the worst recycle chart going where the arrows are all pointing to each other. So, as providers, I think it's very important. Again, we've already talked about, you know, knowing our patients—meeting our patients—but knowing where they are financially. So, to suggest that, you know, if a healthy diet means one thing to a patient who has $122 to last them to payday, and a patient that doesn't have any income or, you know, barriers or ramifications. The other thing that's very concerning, especially like Desiree, I worked in the CMHMC setting for the first 10 years of my career.

And what I've found there is that if you looked at the local WIC programs, and that's federally funded programs that are supposed to help our citizens. Right? And even the low-sodium foods are excluded, low-sugar foods are excluded, low-fat foods are excluded. So, the food programs that are designed to help us eat healthy and keep a normal weight, those foods are excluded. And we're also all educated professionals in this room. I would actually, it'd be a fun challenge to see if we could all get a monthly stipend on what they feel SNAP benefits are and see if we can eat healthy for an entire month or feed a family of four for an entire month with WIC or SNAP benefits, and actually eat a healthy ADA diet based off of the money that we get for support for that.

The other thing we need to acknowledge and point out is that there is a, you know, there's an increase in mental health and depression in inner cities. We know those rates are higher in inner cities. And (in) inner cities, the closest local grocery stores where you could actually not get like a honey bun or Pringles, right (?), but actually get groceries is on the average of 1.5 to 3 miles from the inner cities. And they, and most people, do not have transportation, which further complicates this issue of getting healthy food to our patients, who usually are in the most difficult and most vulnerable positions. So again, I think we just need to acknowledge and meet our patients where they are and when we're making recommendations for a healthy diet healthy exercise. I remember, specifically, one patient I spoke to, I said, “You know, the science is out there. If you could walk even 20 minutes a day, it's going to boost your mood. You're going to feel better.” And she's like, “Okay, let me figure out where I can walk at because, you know, there were just two shootings in my neighborhood last weekend.” And I was like, “Oh, okay.” Again, I didn't know, of course. I didn't viscerally respond, but I didn't realize her situation was that significant. So again, knowing your patients, meeting them where they are, and understanding that sometimes what we might recommend may not actually be accessible to them depending on where they are on their socio-economic status.

Brooke Kempf: Those are such good points, Tina. Desiree, we're ready for your rebuttal.

Desiree Matthews: So, Tina, I cannot argue those points. There certainly are barriers to exercise. There's barriers to access to food, especially healthy food. So, I can certainly acknowledge those barriers. But this is where, you know, working with case management, looking at the resources in the community; we're lucky in my area to have access to farmer's markets within the inner city in order to provide more readily access to fresh fruits and vegetables, eggs, and even meat products. And I can also certainly acknowledge, again, the excitement about the newer treatment modalities or medications that are currently on the market, like esketamine or brexanolone. But again, we cannot preclude the potential to the barriers of even getting those treatments. Again, referrals, wait time, is the medication needing prior authorization? So, we certainly have a lot of medication, you know, barriers to medication treatment as well as, you know. Tina, those barriers that you had mentioned to a modified diet, incorporating the Mediterranean style, exercise.

A lot of times in my clinical practice, I do work with a lot of the local resources, shelter services, services with case management within the county in order to help patients overcome some of these barriers. When it comes to exercising, certainly we can acknowledge that not everybody has a safe place to exercise. They may not feel safe. They might not have access to sidewalks, lanes that they could ride their bicycle may not be there. And the safety may be certainly a concern. However, there are, you know, great apartment-friendly or home-friendly workouts that are accessible right from your phone or computer. We can send patients home with activities like body weight exercising, dance exercising, or dance cardio. So, you do certainly have to get creative. And again, the buy-in does have to be from the patient; otherwise, we're not going to get anywhere. So Tina, again, I can certainly understand those barriers. That is where we can come in as providers to help overcome some of these barriers if possible.

Brooke Kempf: Wow, you guys have brought up just so many different great points. We're ready to hear those closing statements and wrap this round up. Tina, we're going to start with you. Closing statement, please.

Tina Matthews-Hayes: I would just like to focus on a couple words that Desiree just said. The first word was ‘we,’ and the second is ‘resources,’ right? As providers, we're experts. Again, my closing remark is we need to collaborate. We need to know our resources. We need to meet our patients where they are. I know I previously mentioned motivation—motivational interviewing—but that is such an important way of being able to approach a patient regardless of where their socioeconomic status is. Meet them where they are and what, you know, what they're, and where they're willing to make changes and make it a team-wise approach so that you're in partnership with your patient to achieve wellness. Where it's not you just issuing, you know, a list of things they need to do, right? This is a team approach. And as Desiree mentioned, team is, in the fact of, know your resources around you. You know? If you know where the food banks are, know how to get our patients better access to services in the area. But again, knowing, again, that sometimes medication initiation is, you know, with the novel treatments that are coming out, that may be a way to jumpstart them to a healthier long-term end.

Brooke Kempf: Good points. Excellent. Desiree, your closing argument.

Desiree Matthews: So, while medications plays a crucial role in managing depression, we still need to have recognized that exercise and diet modifications, sleep hygiene, meditation, mindfulness, all of these can be very valuable adjunctive treatments to major depressive disorder. And it can complement medication treatments by providing possible immediate benefits, improving mood, and reducing the burden of depressive symptoms. The combination of medication and, exercise and diet changes can offer a comprehensive and whole-body approach to address not only the biological but also the psychological aspects of depression.

Brooke Kempf: You guys have both given us an awful lot to think about, but that concludes round two of our Great Debates series. So, I'm curious to, again, see who the audience thinks won this round. So please go to the poll questions you see on your screen and let us know who you think won this round. But also, don't forget, join us next time. It's going to be our final round, where we're going to discuss how the treatment approach impacts long-term outcomes.