Measuring Treatment Response and Functional Recovery in MDD

Treating major depressive disorder (MDD) goes beyond just medication response, emphasizes Desiree Matthews, PMHNP-BC, Steering Committee, Psych Congress. In this video, Matthews outlines key treatment goals that clinicians should work towards when targeting MDD in clinical practice. In addition to discussing objective scales that can be used to measure treatment progress, Matthews underscores why tracking functional outcomes is an essential part of providing patient-centered care.

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• Key treatment goals to track include response, remission, and functional remission, with early response defined as at least a 25% to 30% symptom improvement within the first few weeks because it increases the likelihood of remission.
• Use the Patient Health Questionnaire-9 (PHQ-9) at baseline and again at 2 weeks to assess early response, with dose escalation considered if improvement is inadequate, and reassess at 4 weeks if patients are still not responding.
• A PHQ-9 score of ≤5 indicates remission, but clinicians should also assess residual symptoms and functional impairment, including cognition and anhedonia, using patient discussion and tools such as the Work Productivity and Activity Impairment (WPAI) questionnaire to evaluate functional remission.

Desiree Matthews, PMHNP-BC: Hi, my name is Desiree Matthews and I'm a board-certified psychiatric nurse practitioner. I'm the founder and clinical director at Different MHP, a telepsychiatry company located in Charlotte, North Carolina.

Psych Congress NP Institute: What are the 3 goals of depression treatment that NPs keep in mind when initiating treatment with a patient? Could you describe a couple of tools that clinicians should use to evaluate patient response to the initial treatment? 

Matthews: When you think about the goals of treating major depressive disorder, in this case unipolar depression we're talking about, there's 3 goals. First, we want to get response, and response can be defined in various literature, but for our purpose, we're going to talk about having at least a 25 to 30% response within the first few weeks of treatment. 

We know that early response is encouraging because early response increases the likelihood that we will get to remission. So first we have to respond to the medication and decrease symptoms. 

Second, we want to get patients to remission. We don't want to stop at response. It's good we've gotten a little bit better, but we want to get to remission. Why? If we get clients to remission, we know that they're less likely to have a relapse in the near future. We want to make sure that they have that resiliency to prevent relapse again. 

And we don't want to stop there. Remission sounds great, but we want to get clients into functional remission.

What does this mean? We're getting them back to their baseline to where they were before having that episode of depression. The question is, how do we measure this?

One of the tools that is really helpful is the PHQ-9. It's freely available. It's in public domain. It's quick. It's easy. You can add it to your intake process. 

What's nice about it is we actually have a nice cutoff that defines mild, moderate, and severe depression. When you take a look, you can do your intake and we can do our PHQ-9 at the beginning, have them come back in 2 weeks. We can have them do it again to see if they have that response, because if they're not getting better, then we need to know what to do next, such as increasing the dose. 

Then, after 4 weeks, if they're still not responding, we need to do something different. But we really need that objective data with something like the PHQ-9. With the PHQ-9, we're aiming for remission as a score of less than 5. 

But keep in mind that I have a client right now I just saw his PHQ-9 is a 4. That's not functional remission because if we talk to him, he will tell you, “Well, I'm still having diminished interest and I'm still having trouble with concentration.” He’s still having some anhedonia and some cognitive impairment from that depressive episode.

Our goal is to improve this over time, whether maybe we need a different mechanism or some other type of intervention to help improve and get him into functional remission. 

We talked about the PHQ-9, but how do we actually measure for functional remission? There is a scale called the WPAI, and there's 1 question—I believe it's question number 6—and it actually addresses impairment in usual activities. “Do you have problems with work? Do you have problems at school?” To measure that in an objective fashion. 

You don’t necessarily have to use that scale, but it's a good way to take a look at how we can ask clients because assessing for residual symptoms of depression is so imperative: If I say a patient is in remission, they might look at me and say, “No, I still can't concentrate. I'm still having trouble focusing at work. I'm still not feeling pleasure in everything that I used to enjoy.” They might look at you and disagree—and this is very common. 

So, assessing for those residual symptoms of depression is really important. Cognition and anhedonia are 2 big residual symptoms of depression that still may be lingering, even if clients are in remission.

Again, my name is Desiree Matthews and thank you so much for joining me. I hope a few of these things were helpful in your day-to-day clinical practice.

Desiree Matthews, MSN, PMHNP-BC, is a board-certified psychiatric nurse practitioner and the founder of Different Mental Health Program, a multi-state telepsychiatry practice providing integrative, patient-centered psychiatric care. Her clinical work centers on the evaluation and treatment of schizophrenia and other psychotic disorders, mood disorders, ADHD, and the identification and management of drug-induced movement disorders.

Ms Matthews is particularly interested in early intervention and longitudinal treatment planning for serious mental illness, with an emphasis on functional recovery and relapse prevention. Her professional interests include long-acting injectable antipsychotics, emerging pharmacologic treatments, and the responsible use of telehealth to expand access while maintaining high standards of care. In addition to her clinical practice, she is actively involved in clinician education and regularly presents on psychiatric treatment planning, practice sustainability, and navigating the evolving mental health care landscape.

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