Round 2: Which approach is better for special populations?

In round 2 of this informative debate, the experts discuss which therapeutic approach is better for special populations struggling with major depressive disorder (MDD).

Dr Charles Raison: Okay. Well, hello, everyone, and welcome back to our Great Debates in Psychiatry series, brought to you by the Psych Congress Network. We are now in round 2 of this debate, and here we're going to be discussing which approach, monotherapy vs multimodal approaches, are better for special populations. And we're going to start again with Dr Banov. So, Dr Banov, go ahead and give us your opening argument.

Dr Michael Banov: Sure. Let me start with the low-hanging fruit on that question. Certainly, younger patients, adolescents—anyone under the age of 24—starting them on a single agent, I think is the most responsible thing to do because we know about the unpredictability of these types of agents in that population. Elderly patients, of course, we're going to probably want to see sooner and probably start with monotherapy because they oftentimes have a lot of comorbid medical conditions, things that we're going to worry more about, side effects, and obviously, combining medications is going to be an issue for that. The patient that comes to me and is very reluctant to get on medications or, and this is not uncommon, someone to come into my office and say, “Oh, I went to this doctor before, and he put me on 3 drugs, and I don’t want to be on all these medications.”

Dr Banov: This obviously is not someone who's going to be very receptive to, and obviously the patient who's had a lot of side effects, problems with other medications in the past. It's going to confuse things for these patients to be on multiple medications at the same time. So again, that's the easy low-hanging fruit, you know, the bigger questions. What about these patients who are sick who are high risk of decompensation? Who really need to be, get better quicker? Are these the kind of patients that we are going to want to start on multimodal therapies? You typically meaning 2 or more agents at the same time. You know, and my response to that is it really kind of depends on the patient. You know, I, what I find, you know, patient acceptance—and we may talk more about this later— is really a key driver to compliance. And, in my opinion, and experience response to their treatments.

Dr Banov: And you have to meet the patient where they're at. The patient that comes to me and is clearly very reluctant to being on polypharmacy. Maybe just has a bad experience, whether it be culturally, maybe it be personally, maybe it was someone they knew who has on been on multiple psychiatric medications. I'm going to be more reluctant to go with that multimodal route because if they don't, we know if they don't take their medicine, they're not going to get better anyway. So that's just the bottom line there. And then, of course, the other, you know, the other kind of patient is the one on the flip side of the coin who always, you always want to feel that they, they want us to do something, you know; and if we don't respond either increasing their medicine or adding something, then we're not really hearing them and not really responding to their needs. So, that might be a kind of patient that may be more open to trying multimodal therapies, although I certainly would try to educate them that these medications take time. And sometimes, giving more medications or a combination of medicines isn't always going to get you the results that you want or need.

Dr Raison: Well said. Okay. That's great. Okay, Dr Measom, let's hear your opening statement on this issue.

Dr Michael Measom: You know, I think it's very clear that Dr Banov and I are both clinicians and like seeing patients, but there's one special population here, and that's the addicted population. I am an addiction psychiatrist, and every opportunity when I'm in the room with somebody who's addicted is an opportunity to help them. Right? And I get the therapeutic alliance by asking the questions. All that's extremely important. My two low-hanging fruit: number 1, elderly population. We all know start low and go slow, but people ask me all the time, “Is my depression from using, or am I using because I'm depressed?” And the answer is yes. So, when you're in the room with somebody, that therapeutic alliance matters. And I agree with Dr Banov about, you know, getting somebody where they want to be. People that I see are not in those studies and people that have dual diagnosis, or whatever you want to call it, or, you know, working on everything. So, if somebody like that wants to get better quicker, I'll do everything I can. If somebody has insomnia, I may use something to help them treat their insomnia, to get them back, and see them at 2 weeks like we talked about before.

Dr Raison: Okay. Dr Banov, your rebuttal to Dr Measom's comments?

Dr Banov: Well, I agree with the concerns about the population with comorbid addiction. Obviously, they're very difficult and challenging, but again, keep in mind these are people that are used to treating their symptoms with pills, or drink, or whatever their drug or substance of choice is. And sometimes giving them the message of, well, we're going to give you multiple pills to take to maybe address anxiety, and sleep, and comorbid symptoms, maybe taking them down a wrong path that maybe we need to communicate. This isn't really all about medication. This is about other things. First of all, let's make sure that you're not using, actively using, even if they tell us they're not. And also encourage other things outside of medications to help them manage their symptoms. And I think we'll make a lot more progress in treating that population without kind of going down that road of unnecessary polypharmacy.

Dr Raison: Okay. Interesting. Dr Measom, your rebuttal to Dr Banov’s rebuttal?

Dr Measom: You know, I believe, and I think we're both talking about the bio-psychosocial, and I would add spiritual model to that. And if somebody needs something in that moment and you want to develop that therapeutic alliance, and if a multimodal treatment is, fits the need, then, you know, don't restrict yourself to monotherapy in that situation. If all else fails, talk to the patient.

Dr Raison: Okay. So, Dr Banov, if you could, summarize your position in a closing statement. Please go ahead.

Dr Banov: The closing statement here is, again, back to the word depends. You know, we don't always want to make absolutes on how we treat patients. Certainly, there are populations that we're going to be more concerned about starting out of the gate with multimodal therapies. And again, I pointed to younger patients, elderly patients, patients with a bad history of reactions to medications. And perhaps there's a place for some patients to start with multimodal therapy. But I think that we have to, again, we have to; our job is to educate our patients about what to expect from medication. And really, my number one and number two goals for my patients is to make sure they're safe and that they don't rapidly decline as well as tolerate their medications. But also, I want to make sure they come back for visit number two. And if they have a bad experience with me with visit number two, they're not coming back for visit number two, which means it may be a longer delay or a complete cessation of treatment.

Dr Raison: Okay. Interesting. Dr Measom, please give us your closing statement.

Dr Measom: Absolutely agree. I mean, I don't know. You know, getting somebody to come back is rule number one when somebody's in your office. But sometimes that, multimodal therapy, some of the things that we use, have some evidence in helping people with other things like addiction, for example. Sometimes, there's something in a multimodal agent that has data helping people decrease use of substances in the future. So, sometimes multimodal, the multimodal therapy makes a difference.

Dr Raison: Okay. Thank you both. All right. So, now this concludes round 2 of our Great Debate series. Be sure to tell us who you think won this round by answering the poll question you see on your screen. And please don't forget to join us next time for our final round, where we will be discussing how should we balance the risk and the reward efficacy vs tolerability of a monotherapy approach vs multimodal therapy approach. So, we'll see you next time to really explore that interesting question.