Evidence for patients’ desires and expectations
The speaker 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 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.
The speaker 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 prefer collaborative relationships with their physicians, and consideration 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.
The presenter 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 the second speaker, who went on to discuss some treatment strategies that would help meet patients’ treatment needs. One size does not fit all, he emphasised, because people have individual symptom sets, and will have varying levels of tolerance to different side-effects. Therefore, algorithmic approaches to treatment can be limited, and physicians will need to individualise patients’ treatment choices. In addition, recent evidence has indicated that pharmacogenetic tests may currently have little to contribute to patient care in depression.1 Instead, physicians will 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 will 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 the presenter, 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.
Any medication or other treatment will also only be effective if the patient takes it regularly, so physicians will 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. The speaker 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.
Present the options, understand what the patient expects and wants, then help the patient make a decision