Section 3


The importance of the patient-provider relationship in MDD treatment


Establishing a therapeutic alliance early in treatment is a powerful remission tool. Interpersonal relationships, including those between the patient and the provider, may impact the course of depression.79

The shared decision-making model


The shared decision-making (SDM) model is one approach through which clinicians and patients with MDD can come together as partners. The key principles of the SDM are outlined in Table 5. 


The SDM model allows providers and patients to collaborate in determining the best course of care. When practiced in the general healthcare setting, the SDM model increases patient knowledge about and comfort with healthcare decisions. Research indicates that use of the SDM model can improve the provider-patient relationship as well as improve patient outcomes such as treatment adherence and treatment satisfaction.80


Incorporating SDM into MDD care


There are many ways to implement the SDM model. The structure, application, and use of specific aids and resources depend on the needs of the clinic and patient population. Example approaches may include81:


  • Mailing decision aids or links to Web-based decision aids to patients prior to an office visit

  • Utilizing health coaches or health educators to work closely with patients to outline treatment options

  • Assigning staff to directly contact newly diagnosed patients and provide information that will help patients choose a course of treatment based on their preferences and concerns

  • Placing interactive, culturally appropriate decision aids at kiosks during health fairs

Time is a precious commodity in most healthcare practices and may be viewed by some as an obstacle to implementing an SDM model in the clinic. In this regard, staff training may represent one barrier to implementing SDM. 


It is important for every staff member who interacts with patients to understand SDM and their role in the overall process. The Agency for Healthcare Research and Quality (AHRQ) offers free accredited training on SDM through the SHARE Approach Workshop. This 1-day train-the-trainer course provides basic information on implementing SDM in clinical practice, specific communication skills, supporting dialogue with patients, and how to find resources to augment SDM in the clinic.81 


Some also may feel that there is no time in an already-busy clinic schedule to incorporate SDM. However, studies indicate that clinicians can implement SDM without increasing the length of consultation time.82-84

One way to accomplish this is by incorporating decision aids and fact sheets.81 Patient decision aids are hard-copy or online interactive tools designed to assist patients in considering their personal priorities when discussing treatment options with their clinician. Decision aids typically include information on a specific condition and associated treatment options. 


Consumer fact sheets may also prove useful. The AHRQ offers a free consumer research summary on depression, providing a disease overview and a review of treatment benefits, risks, and side effects. This document, available in print and online, encourages patients to explore their treatment options and prepares patients to discuss their options with their provider.81

It is important to consider what will work best for your practice, share your plans with clinic staff, and incorporate staff feedback. Starting with a small pilot program may help clinics to identify specific approaches that work best. Once a tactic is successfully integrated and staff feels comfortable, additional approaches may be explored.81

Summary


The goal of treatment in MDD is to achieve full remission.1-4 Unfortunately, remission rates remain low, with some studies reporting that as few as 6% of patients achieve full remission.5

The first step in addressing residual symptoms and supporting remission goals is the use of measurement-based care tactics to monitor and gauge response to treatment. By utilizing validated tools to accurately assess ongoing symptoms and inform treatment decisions, clinicians can better support achievement of sustained remission.28

While antidepressants are a mainstay of treatment for MDD, their association with poor efficacy, high rates of relapse, and often intolerable side effects leave many patients unable to reach their treatment goals.40,41

The APA describes 3 treatment strategies in the management of patients who have an inadequate clinical response to an antidepressant, including increasing the dose of the original antidepressant, augmenting with an additional agent and/or psychotherapy, or switching to a different antidepressant.2 Each of these strategies is associated with specific benefits and limitations and should be considered based on the individual needs of each patient. 


In addition, several antidepressants with novel mechanisms of action have been approved by the FDA and may offer hope to patients experiencing specific residual symptoms or who have concerns about specific side effects. These agents include levomilnacipran, vilazodone, and vortioxetine.60,70,75

Lastly, implementing an SDM model in clinical practice has been shown to support the patient-provider relationship, impact the course of depression, and be a powerful remission tool.79 The SDM model allows providers and patients to collaborate in determining the best course of care.80 The SDM model can be adapted to fit the needs of each clinic, and multiple resources are available from the AHRQ to support implementation.81

For patients with MDD to achieve remission goals, it is imperative that they receive adequate, appropriate, and comprehensive management. Understanding the impact of residual symptoms, utilizing validated tools for monitoring treatment response, considering novel treatment approaches, and implementing strategies that support patient-provider communication and collaboration will ultimately improve patient outcomes and support treatment goals.


Charles L. Raison, MD, is a professor at the University of Wisconsin-Madison in Madison Wis., Catherine R. Judd, MS, PA-C, is a clinical assistant professor at the Southwestern School of Health Professions in Dallas, Texas, and Cindy Parsons, DNP, ARNP-BC, FAANP, is an associate professor of nursing at the University of Tampa in Tampa, Fla.

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