Round 3: Does the treatment approach impact long-term outcomes?

In the final round of this debate, Tina Matthews-Hayes and Desiree Matthews provide their perspectives on whether the treatment approach impacts long-term outcomes for patients.

Transcript:

Brooke Kempf, MSN, PMHNP-BC: Hello, and welcome back to our Great Debates in Psychiatry series brought to you by Psych Congress Network. This is going to be our third round of this debate. We're going to discuss how the treatment approach impacts long-term outcomes. And once again, we're not going to break stride. We're going to pick on you and start with you first, Tina. Can you give us your opening arguments?

Tina Matthews-Hayes, DNP, FNP, PMHNP: Okay, so I believe that, you know, we mentioned STAR*D already in this conversation, so, of course, I'm going to bring it up again. So, I think it's important to acknowledge the fact that we know that every time a patient fails a medication—first-line, second-line— their odds of remission decrease. So again, reemphasizing the use of motivational interviewing and meeting the patient where they are at every single interaction. Not just the first eval, not just that first appointment, but every time they come in. Kind of, you know, testing the water. Seeing where they are and, meeting that patient, and viewing MDD as more of a chronic, ongoing diagnosis, more so than something we can fix rapidly, is very important for the provider. We know that science supports a holistic approach to patient care, but we also need to move at the pace of our patients.

So, if, you know, if we're constantly saying, you know, reiterating the need for therapy and diet and exercise, and they're just not there yet, we have to be comfortable with shifting gears and utilizing medication management when we need to. We know that the APA guidelines, as well as the Florida guidelines, also mentioned earlier use of atypical antipsychotics to reach remission data. Now, that goes back to the risks of metabolic syndrome that Desiree had pointed out. And we're already concerned about weight, and we know that with the use of some atypical antipsychotics, we risk weight gain. But that being said, we can't ignore the fact that adding, you know, using an atypical antipsychotic adjunctively does, in fact, decrease, you know; statistics show that does decrease the rates of depressive symptoms. So, as providers, we really need to have a mastery in pharmacology. We need to know what to write, when to write it, when it's appropriate, and when, if that medication is not working—or as Desiree mentioned—if there's, you know, adverse events, weight gain for, you know, whatever reason, how we can shift gears and get with the end goal of getting our patients across that finish line of the marathon. Again, not the sprint.

Brooke Kempf: Thank you, Tina. Now, Desiree, your opening argument, please.

Desiree Matthews, PMHMP-BC: Thank you, Brooke. So, again, going back to that STAR*D trial, when we look at long-term outcomes of depression, if we looked at that STAR*D trial, the relapse rate within 6 months; if those patients, you know, in the group that achieved remission ranged from 34 to 83%. So, quite a large spread, but also quite high relapse rates. And we have to kind of think to ourselves, well, why are they relapsing? This really shows that we need to explore strategies for preventing the recurrence of depressive symptoms. Once patients are better, how do we keep them well? Considering factors like, again, inflammation, free radicals, or oxidative stress influenced by Western diets can impact neuroplasticity, neurogenesis, and potentially contribute to depression. When we think about the adipose tissue, this promotes pro-inflammatory cytokines that are associated with depression. If we can use diet and exercise, this may help reduce the cytokines and help restore the immune system and potentially experience mood benefits. To achieve optimal outcomes, it's really essential to consider these factors in the development of depressive symptoms, including physical health and nutrition. If we think of the depression and the role of depression and the neurobiology from the view of circuits and nodes, we see that, unfortunately, Western diets and the lack of exercise can play a role in inflammation and really shift our bodies towards decreased neuroplasticity and a decrease in neurogenesis. I really argue that for our mind to be well, we also need to consider these other factors that come into play in terms of what we eat and how our physical health can play a role in the development of depressive symptoms. If we're not addressing the person holistically, I argue we will have a very difficult time achieving optimal outcomes in patients living with MDD. And really, those outcomes are remission, and to stay in remission, and to prevent further recurrence of depressive episodes.

Brooke Kempf: Thank you, Desiree, for bringing up all of those points that are so important for us to consider. Tina, I'm interested in hearing your rebuttal argument.

Tina Matthews-Hayes: Absolutely, and again, we've discussed, you know, the inflammation markers, obesity, and the need for lifestyle modifications in depressed patients, which, again, I fully respect and agree with. But I also want to discuss the alternative medications. I don't feel like we kind of touched on those. I think it's very important for every provider when treating the MDD patient that we ask, “Are you taking any over-the-counter supplements? Any over-the-counter herbal medications? Because I think sometimes those are left off of med sheets, and they can impact the care that we're trying to provide. So that's just something I think would be remiss if we didn't mention in the discussion. But also, the other thing I'd like to bring up is gut health. There's a lot of new research coming out on the importance of gut health in our patients with depression.
Specifically, it's been found that the utilization of some SSRIs and some SNRIs have demonstrated an increase in the bacteria of E ramulus, which is known to have an anti-inflammatory benefit of the body, which thereby decreases depression. So one could argue that if we don't start an SSRI, an SNRI, and we, you know, we may not be getting that anti-inflammatory benefit, which may not decrease depression on a more aggressive scale, or as if we just use lifestyle modifications rather than medications that could, like I said, have an anti-inflammatory benefit to our patient's gut health.

Brooke Kempf: Very interesting. Desiree, your rebuttal, please.

Desiree Matthews: Yeah, so certainly, Tina. I can agree with that, and we even see some antidepressants can help increase BDNF, which is kind of our brain fertilizer the same way that perhaps exercise can. So, sometimes it sounds like we might have two roads maybe leading to the same place, right? [Absolutely.] So, when we talk about treating major depressive disorder, again, we need to get patients into remission. That is what we should be shooting for getting patients into remission in order to prevent poor outcomes in the future, including relapsing or the reoccurring episodes of depression that can come along due to the rates of less-than-ideal remission rates that we see with our traditional antidepressants. Again, a holistic treatment approach maybe taking a step further, but an integrative treatment approach with medication—as well as diet and lifestyle changes, meditation, and psychotherapy—I really believe is the key approach for better long-term outcomes, both physically and mentally. There was one study that was published in Psychosomatic Medicine in 2000. It was (a) pretty interesting study, not a large study. It was 156 adults with major depressive disorder that were currently experiencing an episode of MDD. And we had three treatment groups: one that was prescribed aerobic exercise, there was a medication group, and then a medication plus prescription exercise group. So, it took a look at the three arms, and the study has shown that the remission rates were actually fairly similar across the groups. However, the patients that were in the exercise group or the exercise arm alone had significantly lower relapse rates than the subjects in the medication group after 10 months. So, it seems, potentially, based on this study, that exercise may help with remission rates in depression. So, it's really important as providers to educate patients on the tools and the opportunities to stay well once they're better. And integrating exercise could be one of those strategies.

Brooke Kempf: Absolutely. Desiree, I love focusing on treating patients to remission. We cannot get comfortable with just a response in our treatment. We really do need to focus on treating to remission. Both of you have given us such great information. So, let's conclude with our closing statements for this round. Tina, let's hear a closing statement.

Tina Matthews-Hayes: Absolutely. So, Brooke, I think, you know, one of the phrases I find myself thinking often when treating patients, there has to be a better way. Right? We have to do better. One of the other platforms I preach on is, you know, and we need to be proactive, not reactive, in psychiatry. You know, we need to treat aggressively and get our patients to remission. Get them to wellness and holistic wellness. So, I, you know, with all due respect, you know, in my clinical practice, I view every patient holistically. I will run into the patient that, you know, comes into my door and only wants holistic intervention therapy, as well as, you know, lifestyle changes and suggestions for modifications. And I fully support that patient. But I do also feel that it is my due diligence to educate them that there are some patients that benefit from initiation of medication management, so they have a full understanding of the treatment options and the risk and benefits associated with each of those treatment options. You know, that said, no treatment plan is complete if it's just medications only or if it's not medications. You know, totally an exclusion of medications. I think a holistic approach. I think we can all agree, at the end of the day, is what is going to hopefully get our patients—whether it's current medications, novel medications—you know, so a complete treatment plan that includes, you know, may or may not include medications, should include lifestyle modifications. But again, a collaborative effort with our providers, local resources, will get our patients the support they need to reach remission and hopefully gain mental wellness, not just mental stability.

Brooke Kempf: Yes! Wellness, wellness, wellness! Thank you, Tina. Desiree, your closing statement, please.

Desiree Matthews: Thank you. So, I don't have too much. Tina actually argued my closing statement fairly well. Again, really, the importance of treating depression is getting them into remission and keeping patients well after that. And again, exercise, diet, mindfulness, sleep hygiene, or getting a good night's sleep. All of these can be incorporated, you know, hopefully at a minimal cost to patients and having an overarching impact on the prevention, or really improvement of their other comorbidities that patients may have. In terms of medications, yes, many of my patients are on medications, as well as some of these exercise and diet changes that we can implement. I think, really, the hope is in the future. Looking at medications and medication options for MDD that are moving away from the monoamine hypothesis. And these new and novel rapid-acting treatments for major depressive disorder is where I think we will see a lot of benefits and more optimal outcomes for our patients. As Tina had mentioned, it's hard to get patients, you know, off the couch, out of bed, exercising, food prepping, taking those steps to eat healthy if they are so depressed. If they are suffering from suicidal thoughts. If they are so tired that they can't leave the bedroom. If we can't get them out of bed. If we can't get them sleeping well and motivated enough to implement these holistic measures, then that goes right out the door. So, I think in the future, really the hope is these novel treatments will get our patients better faster, and then we can implement more holistic measures, not only for their well-being mentally but their physical well-being.

Brooke Kempf: Beautiful. You guys have given us just so much to think about. I love it. I love the information you've provided us, but this concludes round three of this installment of our Great Debates series. So again, audience, I want to hear from you. We want to hear from you. Who do you think won round three of this debate? And please answer the poll questions here on your screen, but also be sure to tune in with us next time for closing arguments.