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EFFECTSOFCOMBINED
PHARMACOTHERAPYAND
PHYSICOTHERAPYFORIMPROVINGWORK
FUNCTIONINGINMAYORDEPRESIVEDISORDER.
Chandra kurniawan
Sindya wasundariJohan budiman
Kadek Sinthia
Yuddy Fiyanthi
Winda Dwiastuti
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I. BACKGROUND
Major depressive disorder is a leading cause of work-related disabilityand lost work productivity.
First-line recommended treatments for major depressive
disorder include antidepressants and cognitivebehavioural
therapy (CBT).
The research will combining telephone-delivered CBT with anantidepressant would improve symptom and work productivity outcomescompared with an antidepressant alone.
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II. AIMS
To examine symptom-based and work functioningoutcomes with combined pharmacotherapy andpsychotherapy treatment of major depressive disorder.
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III. METHOD
Employed patients with a DSM-IV diagnosis of major
depressive disorder were treated with escitalopram 1020mg/day for the entire 12 weeks and randomised to :
Outcomes included the MontgomeryAsberg DepressionRating Scale (MADRS), administered by masked evaluators
via telephone,and self-rated work functioning scales
completed online
telephone-administeredcognitivebehavioural
therapy (telephone CBT)
(n = 48)
adherence-remindertelephone calls (n = 51).
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A. PARTICIPANTS
Participant were recrited from clinic referrals and by
advertising at 3 side ( Vancouver, Calgary dan
Toronto).Inclusion Criteria Exclusion Criteria
and out-patients aged 19-
65 years olddiagnosis of major depressivedisorder by DSM-IV criteria
Current paid employment of 15h/week
MADRS score : 19 or higher
Competency to giveinformation
Off work on short- or long- ability
Pregnant of lactating Serious suicidal riskUnstable medical conditionsdiganose of OMD, substancemisuse/dependence.
Use of antidepresant or psychotropic drugs
within 7 days of baseline visit.Treatment-resistance in current episode.Previous use of escitalprolam or CBT fordepression.
Use any additional treatment for depressionduring study.
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B. OUTCOMEASSESSMENTS
Change in the MADRS score from baseline to end-point.
a. Response : if 50% improvement in MADRS scores to
end-point.b. Remission : if end-point MADRS 12
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C. PROCEDURES
Screening + Informed Consent
Make schedule for five study visits (baseline, 2, 4, 8 and 12 weeks) to patient.
Monitored medications and documend adverese event (by psychiatrists).
Rated the patient using the MADRS over the telephone by trained independentevaluators, and masked to treatment assignment and adverse event (by structureinterview guide) within 2 days of each study visit.
Give patient an email with a link tonansecure internet website to complete thestudy quistionares.
Number of Participant : 99 evaluable participant
End Participant : 86 participanteleminated because adverese
events
All comparison were analysed using ANCOVA.
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D. STUDYTREATMENTS
1. Medication
Escitalopram, dose starting with 10mg/ day and increasing to 20 mg/day.
2. CBT
Used a telephone-administrated CBT program (30-40 min instead of 60 min
per session). Eight telephone CBT session were schedule over 8-10 weeks.
Initial session occured within 2 weeks of randomisations Focused on
motivation enhancement excercises. Subsequent sessions occured weeklyFocused in identify, challenging
and distancing from negative thoughts.
Final sessions Focused on a personal care plan and self management
skills.
3. Control Condition
A 10-minute structured telephone call weekly, with enquiry about progress
and reminders to take medication properly.
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IV. RESULTS
a. Clinical OutcomeThere was no signif icant dif ference between the
telephone-CBT and escitalopram-alone groups, with
only small observed effect size (d=0.16).
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b. Work Function Outcome
The work functioning scale did show signi f icantdi f ferences between treatment conditionts. In the LOCFanalysis, the telephone-CBT group had a significantly greaterimprovement than the escitalopram-alone group (p=0.046).
Unfortunately, from baseline to end-point, the escitalopram-alone group had num erical ly higher reduc t ion in hours ofwork missed than the telephone-CBT group.
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V. DISCUSSION
The main results showed that adjunctive
telephoneadministered CBT in combination withescitalopram did not result in differences in
symptom-based clinical outcomes compared with
escitalopram alone; however, the combination
treatment did result in superior improvement insome aspects of work productivity, as assessed by
instruments designed to assess productivity
change.
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Telephone-administered psychotherapy has been
shown in meta-analyses to be more effective than
treatment-as-usual conditions in reducing symptoms
of depression
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CONTDISCUSSION
In this study, telephone CBT was well accepted by
patients, with 79% of participants rating themselves
as satisfied or highly satisfied with the therapy
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VI. LIMITATION
1. The sample size of this study may have limited
power to detect smaller effect sizes in clinical and
functional outcomes
2. Work functioning and productivity was measured
only with self-rating scales
3. the participants were not masked to treatment
condition and the control condition consisted of
adherence reminder telephone calls that were
more brief than the telephone CBT sessions, sowe cannot exclude the possibility that attention,
patient expectations or other non-specific factors
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4. The telephone-delivered CBT used in this study
was a brief (eight, 30-minute sessions)
intervention designed for use in primary care
settings
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CONCLUSION
Combinaed treatment with escitalopram and
telephone administered CBT significantly improved
some self-reported work functioning outcomes, but
not symptom-based outcomes, compared with
escitalopram alone.
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CRITICAL APPRAISAL
AN ARTICLE ON THERAPY19
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