Effective dialogue: Laying the foundation for treating major depressive disorder

Indication:
Trintellix is indicated for the treatment of major depressive disorder (MDD) in adults.

Individual results may vary.

A leading psychiatrist discusses the impact effective communication can have on identifying, diagnosing, and treating patients with MDD.

Psychiatrist Gustavo Alva

Featuring Gustavo Alva, MD, DFAPA

Gustavo Alva, MD, Clinical Assistant Professor, University of California, Riverside; Department of Psychiatry, DFAPA, Founder and Medical Director of ATP Clinical Research in Costa Mesa, California, encounters a variety of patients with diverse neuropsychiatric conditions at his practice, including those with major depressive disorder (MDD). Despite the frequency with which MDD is diagnosed, Dr. Alva notes that patients often aren’t well-versed on what exactly MDD means and can have trouble recognizing and articulating exactly what they’re experiencing. That’s why Dr. Alva stresses the importance of physician-patient communication in effectively navigating through the diagnosis and treatment of MDD.

Beginning the Conversation

“Oftentimes patients aren’t the best of historians,” says Dr. Alva. “They may minimize or mask specific symptoms. On the other hand,” he notes, “they might not even be fully aware of the symptoms they are experiencing. This can make diagnosis challenging, especially when clinicians are beset by so many different medical problems.” To help move these discussions forward, Dr. Alva favors a multi-layered approach that covers the constellation of MDD symptoms and also addresses some of the science behind the condition.

Dr. Alva emphasizes that MDD is a clinical problem and not just a transient occurrence of low mood.10 “There is a big difference between feeling down and depressed on a temporary basis, which we all experience as human beings, and having the clinical manifestations of major depressive disorder,” says Dr. Alva. “Sometimes patients feel reluctant to actually be identified as having clinical depression. That's why education is so important in helping patients understand what a diagnosis of MDD entails.”

“Sometimes patients feel reluctant to actually be identified as having clinical depression. That's why education is so important in helping patients understand what a diagnosis of MDD entails.”

Dr. Alva’s hope is that by discussing symptoms extensively, his patients will have a better understanding of the many ways MDD can affect them and recognize why it’s so important to treat it.

Explaining the science behind MDD to patients, Dr. Alva points out, can be equally challenging. His preferred method is to be as informative as possible, while still using language that is simple for patients to comprehend.

“We’ll generally talk about a disequilibrium in the brain, where different neurotransmitters aren’t necessarily at their right level,” says Dr. Alva. “And that what we’re trying to accomplish with the use of medications is to equilibrate those levels. It’s a very simplistic way of looking at things, but at least it’s one that people can grasp.”11

Having some basic knowledge about the effects of MDD helps Dr. Alva’s patients understand the neurophysiological aspects of MDD and helps them understand the diagnosis. Ultimately, it also prepares them for discussing potential treatment options, including medication, and Dr. Alva notes, following through with treatment recommendations.

Setting Expectations

Managing patient expectations about treatment for MDD can present a number of challenges. “We need to further educate individuals about what treatment entails,” says Dr. Alva. “It’s not like taking an antibiotic where you’re going to take it for a week and then be done with it.”

Patients also need to be aware of the possibility of side effects.10,12 "This is prescription medication,"Dr. Alva notes. "Generally there will be a slew of different side effects that are relatively common with each medicine. I always want to educate individuals about the possibility of side effects and when they might occur, so they can monitor and consult their doctor immediately for help. It also helps them not to prematurely stop the medication without consulting their doctor." In Dr. Alva's experience, the abrupt discontinuation of medication can oftentimes be a problematic issue for a patient's treatment progression.

Setting a Treatment Plan

Major depressive disorder is often a chronic, recurrent medical problem.10 It is generally agreed that acute episodes of major depression should be followed by several months or longer of sustained pharmacologic therapy.10,12 When communicating treatment goals to patients, Dr. Alva likes to frame the conversation not necessarily around remission being defined by a Montgomery-Åsberg Depression Rating Scale (MADRS) total score of ≤ 10, but around adequately addressing the symptoms they are experiencing. According to the American Psychiatric Association, achieving and preserving full symptom remission and preventing recurrence are two of the main goals of treatment.10,12

For Dr. Alva, addressing the recurrence of depressive episodes involves making sure that an individual is adequately monitored.10 Patients might start experiencing their symptoms again like sadness, having trouble sleeping, trouble concentrating, tiredness and loss of appetite.10 “It’s necessary to restart that dialogue with patients around the constellation of symptoms and discuss an appropriate treatment plan in the case of recurrence.”

“It’s necessary to restart that dialogue with patients around the constellation of symptoms and discuss an appropriate treatment plan in the case of recurrence.”

Making Decisions about Treatment

When evaluating potential medication for his patients with MDD, Dr. Alva takes several factors into consideration including treatment efficacy, safety, and tolerability. He feels that the clinical data available on Trintellix helps him consider it as an option for his appropriate patients with MDD.

Trintellix was evaluated in multiple clinical studies including 6 short-term (6‑8 week) studies. One of these studies was done exclusively in geriatric patients, aged 64 to 88.1 Since I see a lot of older patients this information has been helpful.”

“When I’m treating someone who requires longer term care, I want to know that a medication has actually been tested to show a benefit over the long haul. Trintellix has become a treatment choice for me for many patients.” The safety and efficacy of Trintellix was established in 6 short-term (6‑8 week) studies and one long-term (24‑64 week) study in patients with MDD. The primary efficacy measures in these studies were a change from baseline to endpoint of MADRS or HAM-D24 total score, or recurrence of depressive episodes vs placebo.1

Having ample information available positively impacts Dr. Alva’s ability to identify, diagnose, and treat patients with MDD. The more effectively he can communicate with his patients, he says, the fewer difficulties he sees in the continuation of treatment.

Important Safety Information for TRINTELLIX (vortioxetine)

Warning: Suicidal Thoughts and Behaviors

Antidepressants increased the risk of suicidal thoughts and behavior in children, adolescents, and young adults in short-term studies. These studies did not show an increase in the risk of suicidal thoughts and behavior with antidepressant use in patients over age 24; there was a trend toward reduced risk with antidepressant use in patients aged 65 and older.

Warning: Suicidal Thoughts and Behaviors

Antidepressants increased the risk of suicidal thoughts and behavior in children, adolescents, and young adults in short-term studies. These studies did not show an increase in the risk of suicidal thoughts and behavior with antidepressant use in patients over age 24; there was a trend toward reduced risk with antidepressant use in patients aged 65 and older.

In patients of all ages who are started on antidepressant therapy, monitor closely for worsening, and for emergence of suicidal thoughts and behaviors. Advise families and caregivers of the need for close observation and communication with the prescriber.

TRINTELLIX has not been evaluated for use in pediatric patients.

CONTRAINDICATIONS

Hypersensitivity: Hypersensitivity to vortioxetine or any components of the TRINTELLIX formulation. Angioedema has been reported in patients treated with TRINTELLIX.

Monoamine Oxidase Inhibitors (MAOIs): Due to an increased risk of serotonin syndrome, do not use MAOIs intended to treat psychiatric disorders with TRINTELLIX or within 21 days of stopping treatment with TRINTELLIX. Do not use TRINTELLIX within 14 days of stopping an MAOI intended to treat psychiatric disorders. Do not start TRINTELLIX in a patient who is being treated with linezolid or intravenous methylene blue.

Warnings and Precautions

Clinical Worsening and Suicide Risk: All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases. Consideration should be given to changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse, or who are experiencing emergent suicidality or symptoms that might be precursors to worsening depression or suicidality (anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, and mania), especially if these symptoms are severe, abrupt in onset, or were not part of the patient's presenting symptoms. Families and caregivers of patients being treated with antidepressants for MDD or other indications, both psychiatric and nonpsychiatric, should be alerted about the need to monitor patients daily.

Serotonin Syndrome: The development of a potentially life-threatening serotonin syndrome has been reported with serotonergic antidepressants (SNRIs, SSRIs, and others), including TRINTELLIX, when used alone but more often when used concomitantly with other serotonergic drugs (including triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, and St. John's Wort), and with drugs that impair metabolism of serotonin (in particular, MAOIs, both those intended to treat psychiatric disorders and also others, such as linezolid and intravenous methylene blue). Serotonin syndrome symptoms may include mental status changes (eg, agitation, hallucinations, delirium, and coma), autonomic instability (eg, tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia), neuromuscular symptoms (eg, tremor, rigidity, myoclonus, hyperreflexia, incoordination), seizures, and/or gastrointestinal symptoms (eg, nausea, vomiting, diarrhea). If such symptoms occur, discontinue TRINTELLIX and any concomitant serotonergic agents, and initiate supportive symptomatic treatment. If concomitant use of TRINTELLIX is clinically warranted, patients should be made aware of and monitored for potential increased risk for serotonin syndrome, particularly during treatment initiation and dose increases.

Abnormal Bleeding: Treatment with serotonergic antidepressants (SSRIs, SNRIs, and others) may increase the risk of abnormal bleeding. Patients should be cautioned about the increased risk of bleeding when TRINTELLIX is coadministered with NSAIDs, aspirin, or other drugs that affect coagulation.

Activation of Mania/Hypomania: Activation of mania/hypomania can occur with antidepressant treatment. Prior to initiating treatment with an antidepressant, screen patients for bipolar disorder. As with all antidepressants, use TRINTELLIX cautiously in patients with a history or family history of bipolar disorder, mania, or hypomania.

Angle-Closure Glaucoma: The pupillary dilation that occurs following use of many antidepressant drugs, including TRINTELLIX, may trigger an angle-closure attack in a patient with anatomically narrow angles who does not have a patent iridectomy.

Hyponatremia: Hyponatremia has occurred as a result of serotonergic drugs and in many cases, appears to be the result of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Elderly patients and patients taking diuretics or who are otherwise volume-depleted can be at greater risk. More severe or acute cases have included hallucination, syncope, seizure, coma, respiratory arrest, and death. Discontinue TRINTELLIX in patients with symptomatic hyponatremia and initiate appropriate medical intervention.

Adverse Reactions: The most commonly observed adverse reactions for TRINTELLIX in 6- to 8-week placebo-controlled studies (incidence ≥5% and at least twice the rate of placebo) were by dose (5 mg, 10 mg, 15 mg, 20 mg) vs placebo: nausea (21%, 26%, 32%, 32% vs 9%), constipation (3%, 5%, 6%, 6% vs 3%), and vomiting (3%, 5%, 6%, 6% vs 1%).

Drug Interactions: Concomitant administration of TRINTELLIX and strong CYP2D6 inhibitors or strong CYP inducers may require a dose adjustment of TRINTELLIX.

Indication

TRINTELLIX is indicated for the treatment of major depressive disorder in adults.

Please see Full Prescribing Information and Medication Guide for TRINTELLIX.

  1. Trintellix (vortioxetine) prescribing information. Takeda Pharmaceuticals.
  2. Alvarez E, Perez V, Dragheim M, et al. A double-blind, randomized, placebo-controlled, active reference study of Lu AA21004 in patients with major depressive disorder. Int J Neuropsychopharmacol. 2012;15(5):589-600.
  3. Henigsberg N, Mahableshwarkar AR, Jacobsen P, et al. A randomized, double-blind, placebo-controlled 8-week trial of the efficacy and tolerability of multiple doses of Lu AA21004 in adults with major depressive disorder. J Clin Psychiatry. 2012;73(7):953-959.
  4. Boulenger J-P, Loft H, Olsen CK. Efficacy and safety of vortioxetine (Lu AA21004), 15 and 20 mg/day: a randomized, double-blind, placebo-controlled, duloxetine-referenced study in the acute treatment of adult patients with major depressive disorder. Int Clin Psychopharmacol. 2014;29(3):138-149.
  5. Mahableshwarkar AR, Jacobsen PL, Chen Y, et al. A randomized, double-blind, duloxetine-referenced study comparing efficacy and tolerability of 2 fixed doses of vortioxetine in the acute treatment of adults with MDD. Psychopharmacology (Berl). 2015;232(12):2061-2070.
  6. Jacobsen PL, Mahableshwarkar AR, Serenko M, et al. A randomized, double-blind, placebo-controlled study of the efficacy and safety of vortioxetine 10 mg and 20 mg in adults with major depressive disorder. J Clin Psychiatry. 2015;76(5):575-582.
  7. Katona C, Hansen T, Olsen CK. A randomized, double-blind, placebo-controlled, duloxetine-referenced, fixed-dose study comparing the efficacy and safety of Lu AA21004 in elderly patients with major depressive disorder. Int Clin Psychopharmacol. 2012;27(4):215-223.
  8. Boulenger J-P, Loft H, Florea I. A randomized clinical study of Lu AA21004 in the prevention of relapse in patients with major depressive disorder. J Psychopharmacol. 2012;26(11):1408-1416.
  9. Data on file. Takeda Pharmaceuticals.
  10. American Psychiatric Association. Depressive disorders. In: Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Arlington, VA: American Psychiatric Association; 2013:155-188.
  11. Werner F, Coveñas R. Classical neurotransmitters and neuropeptides involved in major depression in a multi-neurotransmitter system: a focus on antidepressant drugs. Curr Med Chem. 2013;20(38):4853-4858.
  12. Gelenberg AJ, Freeman MP, Markowitz JC, et al, for the Work Group on Major Depressive Disorder. Practice Guideline for the Treatment of Patients with Major Depressive Disorder. 3rd ed. Arlington, VA: American Psychiatric Publishing; 2010.
  13. Conradi HJ, Ormel J, de Jonge P. Presence of individual (residual) symptoms during depressive episodes and period of remission: a 3-year prospective study. Psychol Med. 2011;41(6):1165-1174.
  14. Gualtieri CT, Morgan DW. The frequency of cognitive impairment in patients with anxiety, depression, and bipolar disorder: an unaccounted source of variance in clinical trials. J Clin Psychiatry. 2008;69(7):1122-1130.

Important Safety Information for TRINTELLIX (vortioxetine)

Warning: Suicidal Thoughts and Behaviors

Antidepressants increased the risk of suicidal thoughts and behavior in children, adolescents, and young adults in short-term studies. These studies did not show an increase in the risk of suicidal thoughts and behavior with antidepressant use in patients over age 24; there was a trend toward reduced risk with antidepressant use in patients aged 65 and older.

Warning: Suicidal Thoughts and Behaviors

Antidepressants increased the risk of suicidal thoughts and behavior in children, adolescents, and young adults in short-term studies. These studies did not show an increase in the risk of suicidal thoughts and behavior with antidepressant use in patients over age 24; there was a trend toward reduced risk with antidepressant use in patients aged 65 and older.

In patients of all ages who are started on antidepressant therapy, monitor closely for worsening, and for emergence of suicidal thoughts and behaviors. Advise families and caregivers of the need for close observation and communication with the prescriber.

TRINTELLIX has not been evaluated for use in pediatric patients.

CONTRAINDICATIONS

Hypersensitivity: Hypersensitivity to vortioxetine or any components of the TRINTELLIX formulation. Angioedema has been reported in patients treated with TRINTELLIX.

Monoamine Oxidase Inhibitors (MAOIs): Due to an increased risk of serotonin syndrome, do not use MAOIs intended to treat psychiatric disorders with TRINTELLIX or within 21 days of stopping treatment with TRINTELLIX. Do not use TRINTELLIX within 14 days of stopping an MAOI intended to treat psychiatric disorders. Do not start TRINTELLIX in a patient who is being treated with linezolid or intravenous methylene blue.

Warnings and Precautions

Clinical Worsening and Suicide Risk: All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases. Consideration should be given to changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse, or who are experiencing emergent suicidality or symptoms that might be precursors to worsening depression or suicidality (anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, and mania), especially if these symptoms are severe, abrupt in onset, or were not part of the patient's presenting symptoms. Families and caregivers of patients being treated with antidepressants for MDD or other indications, both psychiatric and nonpsychiatric, should be alerted about the need to monitor patients daily.

Serotonin Syndrome: The development of a potentially life-threatening serotonin syndrome has been reported with serotonergic antidepressants (SNRIs, SSRIs, and others), including TRINTELLIX, when used alone but more often when used concomitantly with other serotonergic drugs (including triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, and St. John's Wort), and with drugs that impair metabolism of serotonin (in particular, MAOIs, both those intended to treat psychiatric disorders and also others, such as linezolid and intravenous methylene blue). Serotonin syndrome symptoms may include mental status changes (eg, agitation, hallucinations, delirium, and coma), autonomic instability (eg, tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia), neuromuscular symptoms (eg, tremor, rigidity, myoclonus, hyperreflexia, incoordination), seizures, and/or gastrointestinal symptoms (eg, nausea, vomiting, diarrhea). If such symptoms occur, discontinue TRINTELLIX and any concomitant serotonergic agents, and initiate supportive symptomatic treatment. If concomitant use of TRINTELLIX is clinically warranted, patients should be made aware of and monitored for potential increased risk for serotonin syndrome, particularly during treatment initiation and dose increases.

Abnormal Bleeding: Treatment with serotonergic antidepressants (SSRIs, SNRIs, and others) may increase the risk of abnormal bleeding. Patients should be cautioned about the increased risk of bleeding when TRINTELLIX is coadministered with NSAIDs, aspirin, or other drugs that affect coagulation.

Activation of Mania/Hypomania: Activation of mania/hypomania can occur with antidepressant treatment. Prior to initiating treatment with an antidepressant, screen patients for bipolar disorder. As with all antidepressants, use TRINTELLIX cautiously in patients with a history or family history of bipolar disorder, mania, or hypomania.

Angle-Closure Glaucoma: The pupillary dilation that occurs following use of many antidepressant drugs, including TRINTELLIX, may trigger an angle-closure attack in a patient with anatomically narrow angles who does not have a patent iridectomy.

Hyponatremia: Hyponatremia has occurred as a result of serotonergic drugs and in many cases, appears to be the result of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Elderly patients and patients taking diuretics or who are otherwise volume-depleted can be at greater risk. More severe or acute cases have included hallucination, syncope, seizure, coma, respiratory arrest, and death. Discontinue TRINTELLIX in patients with symptomatic hyponatremia and initiate appropriate medical intervention.

Adverse Reactions: The most commonly observed adverse reactions for TRINTELLIX in 6- to 8-week placebo-controlled studies (incidence ≥5% and at least twice the rate of placebo) were by dose (5 mg, 10 mg, 15 mg, 20 mg) vs placebo: nausea (21%, 26%, 32%, 32% vs 9%), constipation (3%, 5%, 6%, 6% vs 3%), and vomiting (3%, 5%, 6%, 6% vs 1%).

Drug Interactions: Concomitant administration of TRINTELLIX and strong CYP2D6 inhibitors or strong CYP inducers may require a dose adjustment of TRINTELLIX.

Indication

TRINTELLIX is indicated for the treatment of major depressive disorder in adults.

Please see Full Prescribing Information and Medication Guide for TRINTELLIX.

  1. Trintellix (vortioxetine) prescribing information. Takeda Pharmaceuticals.
  2. Alvarez E, Perez V, Dragheim M, et al. A double-blind, randomized, placebo-controlled, active reference study of Lu AA21004 in patients with major depressive disorder. Int J Neuropsychopharmacol. 2012;15(5):589-600.
  3. Henigsberg N, Mahableshwarkar AR, Jacobsen P, et al. A randomized, double-blind, placebo-controlled 8-week trial of the efficacy and tolerability of multiple doses of Lu AA21004 in adults with major depressive disorder. J Clin Psychiatry. 2012;73(7):953-959.
  4. Boulenger J-P, Loft H, Olsen CK. Efficacy and safety of vortioxetine (Lu AA21004), 15 and 20 mg/day: a randomized, double-blind, placebo-controlled, duloxetine-referenced study in the acute treatment of adult patients with major depressive disorder. Int Clin Psychopharmacol. 2014;29(3):138-149.
  5. Mahableshwarkar AR, Jacobsen PL, Chen Y, et al. A randomized, double-blind, duloxetine-referenced study comparing efficacy and tolerability of 2 fixed doses of vortioxetine in the acute treatment of adults with MDD. Psychopharmacology (Berl). 2015;232(12):2061-2070.
  6. Jacobsen PL, Mahableshwarkar AR, Serenko M, et al. A randomized, double-blind, placebo-controlled study of the efficacy and safety of vortioxetine 10 mg and 20 mg in adults with major depressive disorder. J Clin Psychiatry. 2015;76(5):575-582.
  7. Katona C, Hansen T, Olsen CK. A randomized, double-blind, placebo-controlled, duloxetine-referenced, fixed-dose study comparing the efficacy and safety of Lu AA21004 in elderly patients with major depressive disorder. Int Clin Psychopharmacol. 2012;27(4):215-223.
  8. Boulenger J-P, Loft H, Florea I. A randomized clinical study of Lu AA21004 in the prevention of relapse in patients with major depressive disorder. J Psychopharmacol. 2012;26(11):1408-1416.
  9. Data on file. Takeda Pharmaceuticals.
  10. American Psychiatric Association. Depressive disorders. In: Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Arlington, VA: American Psychiatric Association; 2013:155-188.
  11. Werner F, Coveñas R. Classical neurotransmitters and neuropeptides involved in major depression in a multi-neurotransmitter system: a focus on antidepressant drugs. Curr Med Chem. 2013;20(38):4853-4858.
  12. Gelenberg AJ, Freeman MP, Markowitz JC, et al, for the Work Group on Major Depressive Disorder. Practice Guideline for the Treatment of Patients with Major Depressive Disorder. 3rd ed. Arlington, VA: American Psychiatric Publishing; 2010.
  13. Conradi HJ, Ormel J, de Jonge P. Presence of individual (residual) symptoms during depressive episodes and period of remission: a 3-year prospective study. Psychol Med. 2011;41(6):1165-1174.
  14. Gualtieri CT, Morgan DW. The frequency of cognitive impairment in patients with anxiety, depression, and bipolar disorder: an unaccounted source of variance in clinical trials. J Clin Psychiatry. 2008;69(7):1122-1130.