Approximately one-half of patients with major depressive disorder (MDD) will have partial or nonresponse to first-line antidepressant monotherapy, despite receiving an adequate dosage and sufficient duration of treatment.1 This has led to the definition of treatment-resistant depression (TRD) as a depressive episode that has shown insufficient response to ≥1 trial of an antidepressant that has demonstrated efficacy in clinical trials.1 Depressed patients should be treated to full remission because absence of complete remission is associated with:
- a more recurrent and chronic illness course2,3
- increased medical and psychiatric comorbidities
- greater functional burden
- increased social and economic costs linked with impaired social functioning.4
Clinicians need to properly identify MDD and treatment resistance to guide optimal treatment choices. Additional tools are necessary to accurately identify, document, and communicate about symptoms commonly experienced by depressed patients but not fully characterized by DSM-IV-TR MDD criteria.5 Finally, in many cases, trait or situational factors might obfuscate accurate diagnosis and the natural course of illness, and tools that can be implemented practically will help identify patients with MDD.
Our group has created and implemented 2 clinician-administered tools—the SAFER Interview and the Antidepressant Treatment Response Questionnaire (ATRQ)—to enrich the qualitative assessment of MDD and treatment resistance.
SAFER: Assessing the diagnosis, symptom severity
The SAFER interview refines the diagnosis of depressed patients by assessing the state vs trait nature of the symptoms, their assessability, their face and ecological validity, and if they pass the rule of the 3 Ps: pervasiveness, persistence, and pathological nature of the current MDD episode (Table 1 and Table 2).6 This reliable assessment of the patient’s diagnosis and symptom severity is made in a way that reflects the illness in a real-world setting.
Clinical application of SAFER. Implementing SAFER in clinical settings promotes a personalized, dimensional approach by taking into account a varying degree of symptom severity in depressed patients, in contrast to relying on symptom lists as found in the DSM-IV-TR. Using the SAFER interview deepens the typical psychiatric diagnostic process, allows for a more precise understanding of the patient’s situation, and may help clinicians select effective treatments that target specific symptoms, thus resulting in more rapid alleviation of MDD.6
Table 1
The SAFER interview: Assessing depression in a real-world setting
State vs trait nature of the symptoms
|
Assessability
|
Face validity
|
Ecological validity
|
Rule of the 3 Ps
|
| © Massachusetts General Hospital Source: Reference 6 |
Table 2
The SAFER criteria: Rule of the 3 Ps
| Pervasive—Do the major symptoms affect the patient across multiple arenas of life (work, relationships, school, chores, etc.)? |
| Persistent—Do the main symptoms occur most days, most of the day during the current episode? |
| Pathological—Do the symptoms of the present episode interfere with functioning? |
| © Massachusetts General Hospital Source: Reference 6 |
CASE REPORT: Worsening symptoms
Ms. Y, age 53, has been depressed for 30 years. She hardly remembers a time in her life when she felt good for more than a few days. However, 2 months ago she noted her symptoms got worse. She presents with many MDD symptoms as assessed by the Hamilton Depression Rating Scale, eg, ongoing depressive mood, feelings of guilt, major sleep disturbances, and work impairments.
Using SAFER to evaluate Ms. Y, a clinician would ask: Does she have symptoms that are present primarily during an episode of acute illness? Does the episode constitute a measurable exacerbation of preexisting symptoms? This clinical vignette illustrates the importance of the first SAFER criterion, state vs trait nature of the symptoms. Ms. Y is a SAFER “pass”—meaning consistent with a major depressive episode—because exacerbation of preexisting symptoms is measurable. However, if her symptoms represented a chronic, long-standing trait, she would be a SAFER “fail” based on this criterion, and her symptoms likely would not improve during a brief pharmacologic intervention. For such patients, SAFER would have oriented the clinician toward alternative therapies such as psychotherapy or a combination of longer, more complex pharmacologic treatment and psychotherapy.