Evidence-Based Reviews

Personalizing depression treatment: 2 clinical tools

Current Psychiatry. 2012 March;11(3):26-33

References

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CASE REPORT: Limited improvement

Mr. T, age 45, reported that his current depressive episode started several years ago. The first antidepressant trial he received, sertraline, 100 mg/d for 3 months, resulted in 0% improvement. Next he received citalopram, 20 mg/d, for 1 month, without any improvement. The next trial, venlafaxine, 75 mg/d, for 7 weeks, resulted in a 30% response. More recently Mr. B tried duloxetine, up to 90 mg/d, for 2 years with an 80% improvement during the first 3 months and then a decrease of response to <40%. He then received aripiprazole, 10 mg/d, in combination with duloxetine for approximately 4 weeks with no response.

Using the ATRQ to evaluate Mr. B, a clinician would consider the sertraline trial as a failed trial. The citalopram treatment would not be considered an adequate trial because it was too short. The venlafaxine course wouldn’t count as an adequate trial because the dosage was too low. The trial with duloxetine would count as a response (80% improvement) followed by a “poop out” or tachyphylaxis (40% improvement). The fifth trial with the combination of duloxetine and aripiprazole would count as a failed trial. The ATRQ highlights which drugs have been used for too short a duration or at too low a dosage. In Mr. B’s case, using the ATRQ revealed that of 5 trials, only 2 showed antidepressant resistance.

Clinical Point

By assessing if an antidepressant trial had an adequate dose and duration, the ATRQ can help suggest the next treatment options

The ATRQ and decision tree are meant to provide clinicians with user-friendly tools to more precisely determine the number of failed antidepressant trials a patient experienced. By assessing if an antidepressant trial had an adequate dose and duration, the ATRQ can help suggest the next treatment options. For example, if a trial was inadequate in dose and/or duration but the patient tolerated the medication, then optimizing treatment with the current drug would be a logical next step. If a patient does not respond to an adequate trial, clinicians have several options, such as switching to another antidepressant, using a combination of medications or an augmentation strategy, or increasing the dose of the original antidepressant.

Limitations of the ATRQ. Historical rating of treatment is not as accurate as a prospective trial. Another limitation of the ATRQ is that the minimum effective dose is accepted as adequate; many clinicians would suggest that such a dose is inadequate. Also, the duration specified for augmentation, dose increase, and monotherapy are based on expert consensus¹ rather than systematic research. Nonetheless, this method of documenting prior trials and treatment adequacy is an important advance.

The ATRQ lacks a place to indicate discontinuation due to intolerance. Knowing if adverse events caused treatment nonadherence or discontinuation is relevant to selecting treatment.

The ATRQ considers only pharmacotherapy and electroconvulsive therapy. Comprehensive assessment of treatment resistance requires asking about depression-specific, evidence-based psychotherapies, including cognitive-behavioral therapy and interpersonal therapy. Another precaution is that the ATRQ and SAFER should be used in conjunction with structured or semi-structured clinical interviews and other clinical tools to rule out other primary diagnoses (eg, bipolar disorder, posttraumatic stress disorder, obsessive-compulsive disorder, or surreptitious substance abuse).²⁰

Clinical Point

The SAFER and ATRQ should be used in conjunction with structured or semi-structured clinical interviews to rule out other diagnoses

Using SAFER and ATRQ allows clinicians to make a proper MDD diagnosis with an accurate, reliable assessment of symptom severity and a precise count of antidepressant trials of adequate duration and dose. SAFER helps differentiate MDD from other depressive disorders and can be used to separate MDD from a similar presentation of a reaction to external circumstances that may remit if these circumstances change.

These 2 clinical tools focus on MDD and TRD. Compared with treatment resistance in MDD, treatment resistance in other forms of depression, such as minor depressive disorder or dysthymia, has been inadequately researched^21,22 and should be addressed in large studies. However, to help patients achieve remission of depressive disorders—especially MDD—clinicians should use patient information gathered via measurement-based care in combination with algorithm recommendations.²³ Persistence of clinical care of MDD is essential because several treatment steps might be necessary for some patients to achieve remission. Throughout treatment, patients’ symptoms, adverse events secondary to ongoing treatment, and medication adherence should be assessed with appropriate tools. ATRQ and SAFER offer a clinician support in assessing treatment resistance history and a patient’s likelihood to respond to pharmacologic treatment.

Related Resources

Desseilles M, Witte J, Chang TE, et al. Assessing the adequacy of past antidepressant trials: a clinician’s guide to the Antidepressant Treatment Response Questionnaire (ATRQ). J Clin Psychiatry. 2011;72(8):1152-1154.
Targum SD, Pollack MH, Fava M. Redefining affective disorders: relevance for drug development. CNS Neurosci Ther. 2008;14(1):2-9.
Depression Clinical and Research Program. www.massgeneral.org/psychiatry/services/dcrp_home.aspx.