At the 35th ECNP Congress in Vienna, Austria (15th−18th Oct), in a symposium entitled ‘Overcoming barriers in major depressive disorder and schizophrenia: what are we waiting for?’ a distinguished faculty discussed the importance of timely diagnosis and early implementation of management strategies. There are barriers to providing effective therapy that may be overcome by establishing a strong patient-physician relationship and by delivering integrated care. Various approaches to treatment-resistant depression, including augmentation strategies, were also discussed. What is clear is that in both schizophrenia and major depressive disorder, early intervention, complete symptom management and uninterrupted care offer patients the best opportunity for remission and full functional recovery.
Early and integrated intervention improves outcomes
As Dr Charlotte Emborg Mafi (Aarhus University Hospital, Denmark) explained, “the first psychotic episode provides a unique opportunity to intervene to avoid a relapsing course of illness and loss of functional level”. Early intervention starts with psychoeducation and personalized antipsychotic treatment, and can improve the course of illness.
“The first psychotic episode provides a unique opportunity to intervene to avoid a relapsing course of illness and loss of functional level.” – Dr Charlotte Emborg Mafi, Copenhagen, Denmark
Patients are afraid of relapse because they know it can diminish personal autonomy, cause distress to family members, jeopardize relationships and disrupt education and employment.1,2 An integrated approach to care, including assertive community treatment, programs for family involvement and social skills training, is shown to improve clinical outcomes and treatment adherence.3
Fixing the ‘broken brain’
Professor Robin Emsley (Stellenbosch University, South Africa) considered that the underlying fundamental disorder must be adequately treated to achieve full functional recovery. In schizophrenia, the way to fix the ‘broken brain’ is to provide uninterrupted stabilization of dopamine D2 receptors.4 This can be achieved by providing effective, continuous treatment in the early stages of illness.
“Stopping antipsychotic treatment is the strongest predictor of relapse and there is mounting evidence that each relapse may be the critical factor in emergent treatment-refractoriness.” – Professor Robin Emsley, Cape Town, South Africa
“Stopping antipsychotic treatment is the strongest predictor of relapse and there is mounting evidence that each relapse may be the critical factor in emergent treatment-refractoriness”, said Professor Emsley.5 He considered that “the most appropriate use of long-acting injectable antipsychotics is in the early stages of schizophrenia”, for which there is evidence of illness stabilization and improvement in symptomatic and functional remission.6,7
Defining inadequate response in MDD
Turning attention to depression, Assistant Professor Diane McIntosh (University of British Columbia, Canada) considered that many patients with depression have inadequate response (partial/minimal response) to treatment which is less easy to define compared to treatment-resistant depression (TRD).8 What is not in doubt is that inadequate response is a powerful predictor of relapse. She added that “If residual symptoms are left behind, that patient is at a massive risk of having another episode of depression, with ongoing functional impairment and impaired quality of life.” The best chance of achieving remission with treatment is within 6 months of onset of major depressive disorder.9
“If residual symptoms are left behind, a patient is at a massive risk of having another episode of depression, with ongoing functional impairment and impaired quality of life.” – Assistant Professor Diane McIntosh, British Columbia, Canada
Augmentation strategies in MDD
Although effective, Professor Anthony Cleare (Kings College London, UK) identified that very few patients with TRD are given augmentation strategies in clinical practice. However, evidence suggests that augmentation is at least as effective as switching strategies.10,11 “When deciding whether to augment or to switch, building on a partial response is a good strategy” he said. "Consideration of other factors present that may respond well to augmentation therapies include psychoses or bipolar spectrum, and symptoms of anxiety, fatigue and sleep interruption. Patients who have an early response to augmentation treatment, within the first 2 weeks, go on to have a good treatment outcome", he added.12
“Patients who have an early response to augmentation treatment, within the first 2 weeks, go on to have a good treatment outcome.” – Professor Anthony Cleare, London, UK
Educational financial support for this Satellite symposium was provided by Otsuka Pharmaceutical Development and Commercialization Inc., and Lundbeck A/S.
ECNP : European College of Neuropsychopharmacology
MDD : Major Depressive Disorder
TRD : treatment resistant depression
UK : United Kingdom
BE-NOTPR-0235, approval date : 01.2023