How aligned are treatment expectations between clinicians and patients? Even in the era of personalized medicine, research tells us that treatment decisions in depression often do not take into account the hopes, beliefs and expectations of the patient themselves. How to integrate patients’ expectations into the management of depression and the importance of doing so were discussed at this session at ECNP.
Evidence for patients’ desires and expectations
Professor Ellen Frank (University of Pittsburgh, PA, USA) started by saying that in comparison with the large body of evidence on the efficacy of antidepressants, there is little published data on what patients’ expectations are for the treatment of their depression. She reviewed information that was available from patient surveys, focus groups designed to identify priorities for research, qualitative interviews with patients, and direct questioning of patients about what did and did not work in their treatment.
Prof Frank concluded that, in terms of treatment outcomes, patients wanted:
- Relief of symptoms, such as anxiety and negative self-talk
- A sense of well-being and improvements in functioning
- Early intervention, both in the disease, and in each episode of recurrent depression
- Prevention of recurrences.
Patients want collaborative relationships with their physicians, and considerations of their own treatment goals
In terms of their interactions with healthcare professionals, patients wanted:
- Collaborative and egalitarian relationships with their physicians
- Consideration of their specific treatment objectives
- In-depth information about the disorder, and about the interventions that may be useful in treating it, so that patients can make informed treatment choices.
Prof Frank also stressed:
- The importance of respecting the patient’s belief systems and integrating that into their treatment
- The importance of allowing patients to feel unrushed during consultations (albeit in the context of a tight clinic schedule).
One size does not fit all, because people have individual symptom sets, and will have varying levels of tolerance to different side-effects
Meeting individual patient needs
These conclusions were supported by Professor David Castle (University of Melbourne, Australia), who went on to discuss some treatment strategies that would help meeting patients’ treatment needs. One size does not fit all, he emphasized, because people have individual symptom sets, and will have varying levels of tolerance to different side-effects. Therefore, algorithmic approaches to treatment are limited, and physicians need to individualize patients’ treatment choices. In addition, recent evidence has indicated that psychogenomic tests may currently have little to contribute to patient care in depression.1 Instead, physicians need to rely on careful choice of medication and monitoring of therapeutic and adverse effects, and be guided by the patients in their treatment choices.
Physicians need to rely on careful choice of medication and monitoring of therapeutic and adverse effects, and be guided by the patients in their treatment choices
According to Prof Castle, determinants of antidepressant choice include:
- Prior response, of the patient and/or other family members
- Efficacy of the antidepressant in relation to specific symptoms that are of concern to the patient
- Specific tolerability of the drug to the individual patient
- Physicians also need to pay attention to the presence of mixed states, as incorrect treatment of these may make the situation considerably worse for the patient.
Present the options, understand what the patient expects and wants, then help the patient make a decision
Any medication or other treatment will also only be effective if the patient takes it regularly, so physicians need to work with patients to meet their needs and expectations of treatment, and address their concerns; so that the patient is more likely to be adherent. Prof Castle therefore advocated shared decision-making for antidepressant treatment: present the options, understand what the patient expects and wants, then help the patient make a decision on the basis of that.
Educational financial support for this session was provided by SERVIER
To read more about shared decision-making and individualized goal setting in the treatment of MDD, see https://progress.im/en/content/functional-recovery-depression-are-we-doing-right-thing-treatment-depression in Progress in Mind Resource Center.