Using Shared Decision-Making to Guide MDD Augmentation

Selecting an atypical antipsychotic to augment major depressive disorder (MDD) treatment should be a shared decision between both the provider and patient, emphasizes Kevin Williams, MS, MPAS, PA-C. In this video, the Psych Congress Elevate and PA Institute Co-Chair walks clinicians through his patient-centered approach to finding the most appropriate adjunctive treatment option for MDD. Williams highlights the importance of clearly communicating the potential risks and benefits of each option, establishing a well-defined treatment pathway, and collaborating with patients to develop a personalized, effective treatment plan.

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• Selection for augmentation should consider each agent’s psychopharmacology alongside the patient’s symptoms, treatment experience, expectations, and concerns rather than using the same medication for every patient.
• Clinicians can address stigma by explaining why medications historically associated with psychosis are also approved for depression and empowering patients to discuss their treatment with others.
• Clinicians should explain potential adverse effects, establish a plan for managing them, and provide clear communication pathways while allowing patients to guide final treatment decisions.

Psych Congress NP Institute: With several US Food and Drug Administration (FDA)-approved and emerging atypical antipsychotics available for augmentation, how do you approach selecting the most appropriate option—and what are some common barriers mental health providers face when implementing these strategies?

Kevin Williams, MS, MPAS, PA-C: Today, we have several approved options for augmenting treatment for major depressive disorders with atypical antipsychotic medications. My approach has been really based off of the specific psychopharmacology that we have with each particular agent, and ensuring that I'm matching my patient's symptoms and their experience to a particular medication.

I discuss with my patient that all medications aren't made equally and that we have to evaluate each particular medication compared to who they are. I'm not using 1 medication for everyone. 

Also, it’s important to discuss what their expectations and their concerns are. Sometimes when it comes to shared decision-making, the patient is more resistant because of the term “antipsychotic.”

So [I focus on] breaking that barrier and the stigma of the word “antipsychotic,” and really discussing that the term comes from a long lineage where [the medication] was first utilized to treat psychosis, but now we actually have approved treatment for depression, and that is what my patient is experiencing. 

Being able to help my patients by understanding and breaking stigma, then also helping them to [respond] when a family member says, “You're taking what? You're doing what?”  and making sure they feel empowered to have that conversation, eases the patient so that they're able to have that discussion and remain tied to treatment. Then, that starts their journey for improvement of their symptoms.

PCNPI: What role does shared decision-making play in adding an adjunctive treatment, and how can mental health providers effectively communicate the risks and benefits of adding an atypical antipsychotic?

Williams: The term “shared decision-making” has really become quite common in our field in the mental health space. But do we really understand the importance of that phrase, “shared decision-making”?

The approach that I take is I explain to my patient that we're on a journey together. We're on a team. We're going to start this journey one step at a time with me being the facilitator, the clinician, and my patient being the leader and guiding that.

We join in together, me, understanding the science and the patient understanding their experience, and we align ourselves—that's where we get “shared”—in making a decision for their care. 

I always give my recommendations, I give my opinion, I give my thoughts, but the decision is for them to make. And when there's hesitation or there's concerns, we pause. 

“Let's stop. Let's discuss the side effects that are possible. It doesn't mean because there's a side effect profile that you will experience it. But if you do experience the side-effects, what are we going to do about it? I have a plan. That's my job. And here's the plan that we're going to follow. 

If you're experiencing something, let me know immediately. I have a system in place for you to communicate with me, and I communicate back with you, and we are able to discuss what those next steps are.”

So shared decision-making is such a key part of the field of practice in medicine and psychiatry. How we implement it is so key for the success of our patients and the success of our overall care.

Thank you so much for joining me today. I really hope that this information is beneficial and you find it valuable for your clinical practice.

Kevin N. Williams MS, MPAS, PA-C, is the CEO and Lead Clinician at OnPoint Behavioral Health. He is a Physician Associate that specializes in Psychiatry and has a mission to provide care that is experienced, holistic, and compassionate. He holds two master degrees in Interdisciplinary Medical Sciences and Physician Assistant Studies from the University of South Florida and South University respectively. He has gained experience treating children, adolescents, and adults for the past 11 years in the areas of inpatient, outpatient, and long-term care. Kevin has 10 years of experience teaching as an Adjunct Professor at several institutions around the country. Kevin also has over 10 years in executive leadership experience and maintains a passion of educating others to lead with effective influence.

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