www.helsinki.fi/yliopisto treatment of depression in finland – why and how? erkki isometsä,...

www.helsinki.fi/yliopisto

Treatment of depression in Finland – why and how?

Erkki Isometsä, Dr.Med.Sci., Professor of Psychiatry,

Department of Psychiatry, University of Helsinki;

Chief physician (part-time), Department of Psychiatry, Helsinki University Central Hospital (HUCH);

Research Professor (part-time) , National Institute for Health and Welfare, Helsinki

01.09.2014

Potential conflict of finterest disclosure: September 2011 – September 2014

• Employment by a pharmaceutical company: (Never)

• Research funding from a pharmaceutical company: (Never)

• Advisory Board or Speakers Bureau Membership: (Never)

• Honoraria for lecturing in educational meetings sponsored by a

pharmaceutical company

o Servier x 2 (2012)

• Honaria for lecturing, other

o Finnish Medical Society Duodecim (2012)

o Finnish Medical Association (2014)

o European College of Neuropsychopharmacology, ECNP (2012)

o Royal College of Psychiatrists (2012)

o Columbia University (2013)

• Funding for participation in scientific meetings from pharmaceutical

companies

o Lundbeck x 1 (2012)

• Licensed psychotherapist (Valvira)

o Income since 1989

1/273 inhabitants in 2013

medicalization ≠ pharmacotherapy

Why should depression be treated?

Depression and associated disability in Finland in 2012

• Increase in disability pensions

ended 2007.

• No. of sick leave periods 26 709 (no.

part-time sick leaves 1980).

• New disability pensions granted due

to depression for 3 549 individuals.

• Total no. of disability pensions for

depression in Finland 36 358.

• Total costs involved > 600 million €.

Honkonen T & Gould R. SLL 44/2011

Cumulative risk of completed suicide among subjects in psychiatric care in

DenmarkCumulative incidence, register-based follow-up to 36y. (median 18y.) since first treatment contact

Nordentoft M et al., Arch Gen Psychiatry 2011;68:1058-1064.

males females

Treatment: The Finnish Current Care Guidelines

Psychotic depression

Depressive episodes and recurrent depression

<1%

4-5%

10-15%

Annual prevalence of depressive syndromes in the general population

mild depressive symptoms

Dg F32-33

Phases of treatment

Acute treatment

Continuation phase

Maintenance phase

6 mo. Recurrent depression (F33)

relapse recurrence

Current Care Guidelines, 2009

Acute treatment of depression

Treatment modality Mild Moderate Severe Psychotic

Psychotherapies + + (+) -

Antidepressants + + + +

Antipsychotics - - - +

Electroconvulsive therapy (ECT)

- - + +

Current Care Guidelines, 2009

Psychotherapeutic treatment

Central forms of psychotherapy in different treament phases

Treatment modality Duration and intensity Evidence in phases of treatment

Acute Continuation and maintenance

Chronic and/or complicated

Cognitive /Cognitive-behavioural (CBT)

A - -

Brief MBCT (8-16x, 1x/wk) - A -

Brief/medium-term CBASP (12-40x)

- - B

Long-term (40-160x, 1-2x/wk)

D D C

Interpersonal (IPT) Brief (12-16x, 1 x/wk) A A -

Psychodynamic Brief (16-25x, 1x/wk) B - -

Long-term (80-240x, 1-3x/wk)

B D B

Current Care Guidelines, 2009

MBCT = mindfulness-based cognitive therapy; CBASP = cognitive behavioral analysis system of psychotherapy

Effectiveness of psychotherapy in depression?

• In the Helsinki Psychotherapy Study (HPS, N=326), patients depression/and or anxiety improved significantly on both brief and long-term psychodynamic as well as solution-focused therapies, but brief therapies were estimated not to be sufficient treatment in the majority of patients.

• In a study (N=341) comparing cognitive-behavioral vs. psychodynamic brief therapies (16 sessions in 22 wks) in outpatients psychiatric care in Amsterdam, proportion of patients remitted 23% in both groups, responders 39% and 37% (Driessen E et al., Am J Psychiatry 2013;170:1041-50.)

• In the UK Improved Access to Psychological Therapies (IAPT) Project, a report of 7859 pts found 55% of patients improved after treatment. However, attrition rate was 47% (Richards & Borglin, J Affect Disord 2011;133:51-60).

Psychotherapy: the issue of capacity

• Overall 5475 licensed psychotherapist aged ≤ 65 y in 31.12.2013

(Valvira).

• In 2009-13, no. of registered new therapists varied annually

between 275-432.

• Of Finnish psychotherapists in 2011,

o ¼ were not currently providing psychotherapy

o 85% provided individual therapy

o Median time devoted to psychotherapeutic work 15h/wk

o Estimated no. of patients treated per year 18 pts./therapist

o Regional distribution uneven, 3-fold differences in density

Rough estimate: 40 -70 000 patients treated/year, in therapies of 1-3 y

Valkonen J et al. Psykoterapeutit Suomessa. Psykoterapiapalvelut ja niiden järjestäminen. KELA, 2011

Pharmacotherapy

• Altogether 444 184 individuals in

2012.

• DDD 69,81 (DDD 70,24 in 2011)

• Change from the year 2011: -1%.

• Likely causes of increase:

• Increased treatment-seeking and

provision for depression,

particularly in primary health care

• New treatment indications

• Continuation/maintenance

treatment

Finnish Statistics on Medicines, 2012

Sales of antidepressant drugs in Finland in 1990-2012

• Altogether 444 184 individuals in

2012.

• DDD 69,81 (DDD 70,24 in 2011)

• Change from the year 2011: -1%.

• Likely causes of increase:

• Increased treatment-seeking and

provision for depression,

particularly in primary health care

• New treatment indications

• Continuation/maintenance

treatment

Finnish Statistics on Medicines, 2012

Sales of antidepressant drugs in Finland in 1990-2012

Current Care Guidelines

From: Health Statistics for the Nordic Countries; Nomesko, 2013

Sales of antidepressants in the Nordic countries in 2005-2012

Spontaneous remission

Placebo Antidepressant0%

10%

20%

30%

40%

50%

60%

Typical 6-8 wk antidepressant trial response rates

Spontaneous remission

Placebo Antidepressant0%

10%

20%

30%

40%

50%

60%

Typical 6-8 wk antidepressant trial response rates

The THREAD Study (N=220) : Effectiveness of SSRI-treatment added to supportive treatment in UK primary care

Remission by 12 wks: 42% vs. 24%, NNT = 6 (95% l.v. 4-26)

Kendrick T et al. Health Technology Assessment 2009;13:22. DOI:10.3310/htaI 3220

Phases of treatment

Acute treatment

Continuation phase

Maintenance phase

6 mo. Recurrent depression (F33)

relapse recurrence

Current Care Guidelines, 2009

NNT 3-6

Conclusions

• Depression is associated with remarkable disability, significant excess mortality, and markedly elevated suicide mortality.

• In mild to moderate depression, there are no significant differences in efficacy or effectiveness between psychotherapies or antidepressants.

• In severe or psychotic depression pharmacotherapy or other biological treatment is usually needed.

• Combined and integrated treatments are needed and most effective.