Screening for Bipolar I Disorder and the Rapid Mood Screener: Results of a Nationwide Health Care Provider Survey.

Objective: Effective screening for bipolar I disorder can lead to enhanced assessment, improved diagnosis, and better patient outcomes. The Rapid Mood Screener (RMS), a new bipolar I disorder screening tool, was evaluated in a nationwide survey of health care providers (HCPs).Methods: Eligible HCPs were asked to describe their opinions/current use of screening tools, assess the RMS, and evaluate the RMS versus the Mood Disorder Questionnaire (MDQ). Results were stratified by primary care and psychiatric specialty. Findings were reported using descriptive statistics; statistical significance was reported at the 95% confidence level.Results: Among respondents (N = 200), 82% used a tool to screen for major depressive disorder (MDD), while 32% used a tool for bipolar disorder. Most HCPs were aware of the MDQ (85%), but only 29% reported current use. According to HCPs, the RMS was significantly better than the MDQ on all screening tool attributes (eg, sensitivity/specificity, brevity, practicality, easy scoring; P < .05 for all). Significantly more HCPs reported that they would use the RMS versus the MDQ (81% vs 19%, P < .05); 76% reported that they would screen new patients with depressive symptoms, and 68% indicated they would rescreen patients with a depression diagnosis. Most HCPs (84%) said the RMS would have a positive impact on their practice, with 46% saying they would screen more patients for bipolar disorder.Discussion: In our survey, the RMS was favorably evaluated by HCPs. A large percentage of respondents preferred the RMS over the MDQ and indicated that it would likely have a positive impact on clinicians' screening behavior.

Considerations when selecting an antidepressant: a narrative review for primary care providers treating adults with depression.

Major depressive disorder (MDD) is a debilitating mental disorder that can be treated with a number of different antidepressant therapies, each with its own unique prescribing considerations. Complicating the selection of an appropriate antidepressant for adults with MDD is the heterogeneity of clinical profiles and depression subtypes. Additionally, patient comorbidities, preferences, and likelihood of adhering to treatment must all be considered when selecting an appropriate therapy. With the majority of prescriptions being written by primary care practitioners, it is appropriate to review the unique characteristics of all available antidepressants, including safety considerations. Prior to initiating antidepressant treatment and when patients do not respond adequately to initial therapy and/or exhibit any hypomanic or manic symptoms, bipolar disorder must be ruled out, and evaluation for psychiatric comorbidities must be considered as well. Patients with an inadequate response may then require a treatment switch to another drug with a different mechanism of action, combination, or augmentation strategy. In this narrative review, we propose that careful selection of the most appropriate antidepressant for adult patients with MDD based on their clinical profile and comorbidities is vital for initial treatment selection.Strategies must be considered for addressing partial and inadequate responses as well to help patients achieve full remission and sustained functional recovery. This review also highlights data for MDD clinical outcomes for which gaps in the literature have been identified, including the effects of antidepressants on functional outcomes, sleep disturbances, emotional and cognitive blunting, anxiety, and residual symptoms of depression.

Major depressive disorder (MDD) is a leading cause of disability worldwide and can affect each patient differently. Antidepressants play a critical role in treatment; however, with multiple antidepressant options available, it is important that providers select the best fit for each patient. Rather than use a "one size fits all" approach, it is important to consider each patient's symptoms, medical and psychiatric comorbidities, as well as their treatment preferences. A clear summary of each antidepressant's distinctive characteristics is essential for providers to select antidepressants to best match each patient's needs.This narrative review aims to discuss the latest information on available antidepressants, including their risks and benefits and how they impact symptoms of MDD such as sleep disturbances, anxiety, emotional blunting, and changes in cognition, as well as different treatment goals, such as the ability to function in everyday life. This information can guide clinical practice recommendations and further enable shared decision-making between the provider and patient, incorporating individual treatment needs and preferences.In addition, many patients do not reach their treatment goals with the first antidepressant or may continue to have symptoms of depression after treatment. This review discusses strategies to increase the likelihood of symptom improvement and creates awareness of patient-specific considerations.Overall, careful, personalized selection of antidepressant treatment is critical for finding the right balance of maximized antidepressant effect with minimized side effects, leading to the best possibility for patients to tolerate the medication and ultimately helping patients reach their treatment goals.

Practical Advice for Primary Care Clinicians on the Safe and Effective Use of Vortioxetine for Patients with Major Depressive Disorder (MDD).

Primary care clinicians have a vital role to play in the diagnosis and management of patients with major depressive disorder (MDD). This includes screening for MDD as well as identifying other possible psychiatric disorders including bipolar disorder and/or other comorbidities. Once MDD is confirmed, partnering with patients in the shared decision-making process while considering different treatment options and best management of MDD over the course of their illness is recommended. Vortioxetine has been approved for the treatment of adults with MDD since 2013, and subsequent US label updates indicate that vortioxetine may be particularly beneficial for specific populations of patients with MDD, including those with treatment-emergent sexual dysfunction and patients experiencing certain cognitive symptoms. Given these recent label updates, this prescribing guide for vortioxetine aims to provide clear and practical guidance for primary care clinicians on the safe and effective use of vortioxetine for the treatment of MDD, including how to identify appropriate patients for treatment.

Implementing Measurement-Based Care to Determine and Treat Inadequate Response.

​​ Measurement-based care (MBC) is an important strategy in the treatment of patients with major depressive disorder who have inadequate antidepressant response. The rating scales used in MBC can assist clinicians at critical decision points, such as when to declare a treatment failure, what to do with partial improvement, and how long to continue successful treatment. Measurement has two benefits: it gives the clinician an objective basis for comparison of symptom severity over time, and it helps patients to have insight into their illness course. Further, many of these tools do not add substantially to the length of the clinical visit. MBC can also be used to monitor and address residual symptoms such as fatigue and irritability that impact patients' functioning and quality of life.​ ​.

Recognizing Inadequate Response in Patients With Major Depressive Disorder.

​​ ​​ Being able to recognize inadequate response to antidepressant treatment and distinguish it from treatment-resistant depression is key in order for clinicians to provide appropriate therapies. Although definitions vary, nonresponse is often defined as less than 25% improvement on a standardized rating scale, and partial response, as more than 25% but less than 50% improvement. Residual symptoms characteristic of inadequate response (less than 50% improvement) include low mood, anxiety, irritability, guilt, and somatic symptoms. Various factors that may contribute to inadequate response to an antidepressant include inadequate dose or duration, poor adherence, and misdiagnosis. ​.

Inadequate Response to Treatment in Major Depressive Disorder: Augmentation and Adjunctive Strategies.

​​​​ About 30%-50% of patients experience inadequate response to antidepressant therapy, and treatment choices for these patients include augmenting the antidepressant with another therapy, increasing the dose, switching to a different antidepressant, or combining antidepressants. Clinicians should tailor treatment strategies based on patients' response, tolerability, and disease severity. In this activity, augmentation and adjunctive strategies involving atypical antipsychotics, as well as off-label options including buspirone, stimulants, thyroid hormone, and lithium, are reviewed.​ ​.

Overcoming Challenges to Treat Inadequate Response in Major Depressive Disorder.

​​ ​​ When a patient with major depressive disorder experiences inadequate response to an antidepressant, clinicians should employ measurement-based care strategies to improve outcomes. Evidence suggests that adjunctive therapies, such as the FDA-approved atypical antipsychotics, are efficacious when the initial treatment is well tolerated but not improving symptoms. Clinicians should consult guidelines, peer-reviewed journals, CME programs, and other sources to stay up-to-date with current and emerging treatments in this area. They should also be familiar with the available options for psychotherapy, neurostimulation, supplements, and exercise for patients who prefer alternative therapies. ​​.

The benefits of measurement-based care for primary care patients with depression.

Follow the case of Mrs C, a primary care patient with depression who fails to respond to initial antidepressant treatment, and see how measurement-based care helps her clinician confirm her diagnosis, track symptom response, and assess her sense of well-being. Using rating scales such as the 9-item Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder 7-item scale (GAD-7), and Mood Disorder Questionnaire (MDQ) can help clinicians recognize suboptimal response and make treatment adjustments such as optimizing the medication dose, switching to another medication, or augmenting with medications, psychotherapy, or exercise. For Mrs C and other patients with depression, the goal of treatment must go beyond symptom remission to improve quality of life.

Developing a therapeutic plan for treating MS: evidence for new treatments.

Patients with multiple sclerosis (MS) require an individualized treatment plan that will help slow disability progression and reduce the number and duration of relapses. The available disease-modifying therapies are approved for relapsing forms of MS, with one agent also approved for secondary progressive MS. Clinicians must know the benefits and adverse effects associated with these treatments and guide patients to the most appropriate medication tailored to their disease course and presentation, as well as to their preferred administration method. To treat relapses that have not spontaneously remitted, clinicians may use short-term steroids (IV or oral formulations) or, for acute relapses in patients who cannot tolerate steroids, plasma exchange or IV immunoglobulin (IVIG). Patients may also have questions regarding complementary and alternative medicines, so clinicians should know which options are most promising for patients with MS.

Depression, pain, and comorbid medical conditions.

Depression commonly co-occurs with medical illnesses and chronic pain, which can contribute to the somatic symptoms of depression, complicate diagnosis and treatment, worsen patients' prognosis, and hinder recovery. Many therapies are available to treat depression, but patients with depression and pain or medical conditions may require a different treatment strategy than those with depression alone. This activity focuses on the best methods for recognizing and diagnosing these conditions, selecting appropriate therapies to create comprehensive treatment plans, and monitoring and educating patients to improve their quality of life.

Assessing and managing pain and major depression with medical comorbidities.

Chronic pain is the leading reason patients see their primary care physician, and the burden of pain and depression in those with medical illness is particularly severe. Improving depressive symptoms can decrease physical symptoms in many patients, but these patients may require a different treatment strategy than those with depression alone. This activity provides guidance on recognizing and accurately diagnosing pain and major depression, managing these conditions using assessment tools and measurement-based care, avoiding unwanted side effects and drug interactions, and properly matching patients to appropriate treatments.

Beyond the resistance: how novel neurobiological understandings of depression may lead to advanced treatment strategies.

For patients with depression, antidepressant response rates are generally low and residual symptoms can increase the risk of relapse. Poor response may be linked to increased inflammatory cytokines and obesity. Specifically targeting inflammation with adjunct l-methylfolate treatment may help patients with depression finally achieve remission. In this Webcast, experts examine the multi-directional relationship between obesity, inflammation, and depression, consider preliminary data on genetic alleles, and review evidence using l-methylfolate as a targeted therapy.