Dr Vladimir Maletic on the Challenge of Treating Major Depressive Disorder

Patients with childhood trauma may have reduced response to antidepressant agents, and physician need to be given more free rein to tailor treatment approaches to treat those with major depressive disorder, said Vladimir Maletic, MD, MS, clinical professor of neuropsychiatry and behavioral science at the University of South Carolina School of Medicine.

What considerations should payers make for behavioral healthcare for adults who  can document emotional trauma in childhood?
If individuals have documented history of trauma in their childhood, the odds are that they may have reduced response to antidepressant agents. In addition to that, we need to recognize that major depressive disorder (MDD) as a single biological entity does not exist. So we're not treating depression; we're treating depressions.

There has been a large study with over 1000 patients, it's an imaging study looking at the pattern of brain activity in individuals who have MDD and looking at their symptomatic expression. What has been concluded is that there are at least 4 subtypes of major depressive disorder. On the other hand, symptomatic presentation does not tightly correlate with biological subtypes. Therefore, just looking at the symptoms we cannot really distinguish what is going on biologically in these individuals' brains.

Why is that important in this context? For a very simple reason: these individuals already have a hard time responding to pharmacotherapy. Number 1, they do need coverage for psychotherapy, because otherwise our ability to help them is significantly reduced. Number 2, we need to have more free rein to choose pharmacotherapeutic agents given the depression is already biologically diverse. So there will never be 1 treatment fits all for treatment of major depressive disorder. And a fallacy that has been propagated is we look at remission and response rates, and across the classes of antidepressants they appear to be similar. It does not mean that they are 1 and the same patients. Because it is a diverse condition.

So I think the physicians should be given more opportunity to tailor treatment approach both in combination of psychotherapy and pharmacotherapy, and to choose pharmacological agents that are most likely to result in remission and response in this very difficult to treat group of depressed patients.
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