How to reach full remission of symptoms

Definitions

Partial response: 25-50% reduction in symptoms

Response: 50% or greater reduction in symptoms

Remission: resolution of sxs PHQ9 or GAD7 < 5

The goal of treatment should be a rating scale score of as close to 0 as possible

Two desirable options: 

1) being on an effective dose of a medication 

2) not being on the medication at all

Not a desirable option: being on a medication that is not (fully) effective

Case presentation

Middle age F pt

On an SSRI x years ~ Zoloft 50mg

PHQ9 of 11, GAD7 of 12

Med continued at the same dose

What is the issue here? = Patient is in partial response

Partial response = pt responding to the medication but not getting fully better. Here, the dose would have needed to be increased…

Factors accounting for partial response

-> Clinician’s side

Lack of clinical “compass” on the clinician’s side

Going with what the patient says eg. “my anxiety will always be there”

Lack of a thorough assessment (What are we treating?)

Reluctance to increase dose due to “fear” of meds (?)

Pt “does not want to increase the dose”

Patient is being patient, your job is to give clinical input for them to make an informed decision

Letting the patient make decisions without educating them sufficiently “I want XYZ meds” which may not be the appropriate treatment (beware of the very popular Wellbutrin which is NOT an appropriate medication for a lot of people)

-> Patient side

Patient is someone you can’t convince to take enough meds (usually anxious patients). Related: Appropriate use of PRNs

Course of illness - Slipping BACK from full to partial response. Potential causes:

-> New stressors - pt going through a tough time; pt can slip back, dose increase needed

When pt is going through a tough time (stressors, triggers), they may need a higher dose than before to feel symptom free.

• if stressor is time limited, use PRNs

• if stressors is expected to linger, increase the standing dose

Medication “poop-out” (medication losing efficacy); better off stopping and using something else. In the future you may be able to restart

Reference:

Positive anxiety or depression screen despite ongoing antidepressant prescription…”low antidepressant doses were associated with positive screens” link HERE