Remission vs. Response: Redefining Treatment Goals in Major Depressive Disorder

In this episode, "Remission vs. Response: Redefining Treatment Goals in Major Depressive Disorder," the mental health experts explored the following questions:

Major depressive disorder (MDD) is a heterogeneous disorder with many unique symptom combinations. How does that clinical complexity affect how clinicians define treatment goals, and what does an adequate response mean in terms of treatment goals?

How do treatment goals differ for remission versus response, and why does that distinction matter for managed care quality metrics?

Only 1 in 3 patients achieves remission with their first antidepressant, and response rates continue to decline with each subsequent treatment step, as the STAR*D data have shown. What does the inadequate antidepressant response landscape look like in practice, and where do we typically lose patients?

Approximately 50% of patients with MDD have inadequate response after 6–8 weeks of antidepressant therapy — what are the clinical and administrative signals that prompt the next treatment decision?

When a patient has an inadequate response to antidepressants, what are the current options for augmentation and switching, and how do atypical antipsychotics fit within that hierarchy?

At what point in the treatment algorithm do clinicians typically consider adjunctive antipsychotic therapy, and what patient factors drive that decision?

The panelists examined how MDD's clinical heterogeneity requires individualized treatment plans, with Samuel Wilkinson distinguishing remission — where patients become indistinguishable from those without depression — as a higher, more stabilizing goal than response, defined as a 50% symptom improvement. Michael Thase reviewed STAR*D data showing only one in three patients achieve remission with their first antidepressant, with roughly 10% patient attrition at each unsuccessful treatment step, and outlined early warning signs, such as lack of improvement within the first two weeks, that should prompt dose titration or a treatment change. Wilkinson and Nisha Bhide closed by outlining the switch-versus-augment decision framework, noting that switching is generally preferred after minimal response at a maximized dose, while augmentation, often with atypical antipsychotics, is favored for partial responders, with metabolic risk considerations typically delaying antipsychotic use until after two failed antidepressant trials.

Throughout the conversation, the experts provided a comprehensive reflection on the field and the factors that may shape how clinicians approach care moving forward.

The next episode in this series, "Unmet Needs and Mechanisms: Understanding Adjunctive Antipsychotics in MDD," features the panelists advancing their conversation on major depressive disorder and focusing on persistent efficacy, tolerability, and adherence gaps in antidepressant treatment, the impact of metabolic side effects on total cost of care, and the shared mechanisms and key pharmacologic differences among the five FDA-approved adjunctive atypical antipsychotics.