hanipsych, functional recovery in depression
TRANSCRIPT
Functional Recovery in DepressionFunctional Recovery in Depression
Prof. Hani Hamed Dessoki, M.D.Psychiatry
Prof. Psychiatry
Chairman of Psychiatry Department
Beni Suef University
Supervisor of Psychiatry Department
El-Fayoum University
APA member
Disclosure
• Some promotional data provided by Lundbeck Egypt.
Digestive disorder (6%) Musculoskeletal
disorders (4%)
Endocrine (4%)
Neuropsychiatricdisorders (28%)
Cancer (11%)
Cardiovascular disease (22%)
Sense organ impairment (10%)
Other non-communicable diseases (7%)
Respiratory disease (8%)
Schizophrenia
Bipolar disorder
Dementia
Substance-use andalcohol-use disorders
Other mental disorders
Epilepsy
Other neurological disorders
Other neuropsychiatric disorders
MDD
2%
10%
2%
2%
4%
3%
1%
2%
3%
Prince et al. Lancet 2007;370(9590):859–877
Contribution (%) by different non-communicable diseases to disability-adjusted life-years (DALYs) worldwide in 2005
Psychiatric disorders – underestimated and disabling conditions
يصيب • أصبح الذي والعصبي النفسي سطح 450المرض فوق إنسان مليوناألرض.
الي • وصل وحده االكتئاب , 140وان انسان مليون
الي • العالم في وصلت فقد والخوف القلق حاالت خائف 200أما انسان مليونوقلق..
الي • أيضا العالم في اإلدمان .. 130ووصل مدمن إنسان مليون
و • مليون وجود تؤكد فإنها مصر في األرقام يعاني 200أما مصري إنسان ألف. االكتئاب عذاب
2011-10 -20االهرام
Face the Facts
Depression is a Prevalent Disorder
The global burden of disease, 1990−2020
• Lower Respiratory Infections
• Diarrheal Diseases• Perinatal conditions• Depression• Heart Diseases• Cerebrovascular D/O
• Heart Diseases• Depression• Traffic accidents• Cerebrovascular D/O• COPD• Lower Respiratory
Infections
Lopez et al :Global burden of disease and risk factors, Oxford University Press, New York (2006)
Ten leading causes of burden of disease, world, 2004 and 2030
Depression IssuesDepression Issues
• Depression exists on a continuum• Major depression is quite common
• Lifetime prevalence rates range from 5.2% to 17.1%• Women are twice as likely to develop depression as are men• Higher rates in young adults and among individuals in lower
socioeconomic groups. • Depression prevalence varies across cultures
• Prevalence of depression has been increasing over the last 50 years
Depression
20% of those with major depression have symptoms that
persist beyond 2 years
Keller et al., (1992) & Scot & Dicky (2003), B. J. Psychiat.Keller et al., (1992) & Scot & Dicky (2003), B. J. Psychiat.
Depression In Primary Care
• Prevalence of depression in Medically ill patients is twice that of General populations
• Medical Disease is a risk factor itself for Depression
• Rates of Depression increases with Acuity of care from low 9% in general population to 30% in acutely hospitalized patients
Fava: J clin Psych Primary Care Companion 2005
Depression is an Under-recognized Disorder
Stigma
Masked depression
Comorbid medical illness
Time constraints
Inadequate medical education
“ICEBERG” PHENOMENON”
Depressed patients seen by psychiatrists
Depressed patients seen in primary care practice
Cost of DepressionWho pays for it?
• Patients• Families• Health Care Provider• System
Cost of Depressionto Patients
• Unable to cope effectively• Affects nutrition, Rx adherence, self care• More likely to have adverse reaction to medications• Poor physical functioning• Increased Morbidity and mortality
Cost of DepressionFamilies
• Increased burden• Patient being aloof from family causing more guilt and
anxiety• Impaired relationship• Increased risk of violence and neglect
Cost of DepressionHealth Care Providers
• More likely to order work up• Feelings of detachment• May give up early• Feelings of being a failure or not doing enough
System
• Increased use of resources• Increased mortality and morbidity
Unmet Medical needs
GPs delayed diagnosis
Cross diagnosis of
Bipolar
Stigma Selecting the right treatment option
From IV to 5
COSTDirect
• Recurrence
• Treatment
• Hospitalization
Indirect
• Disability in work
• Poor social function
• Associated behavioral
problems
• Increase self destructive
behaviors
Indirect
• Disability in work
• Poor social function
• Associated behavioral
problems
• Increase self destructive
behaviors
Lost productivity—55%
Outpatient care—6%
Suicide—17%
Inpatient care—19%
Pharmaceuticals—3%
Greenberg PE, et al. J Clin Psychiatry. 1993;54:405-418.
Economics of Depression —U.S.A. Data - Total Annual Cost ~$44 Billion
U.S. data.
‘Presenteeism’ is a greater problem than absenteeism
Absenteeism• Time spent away from the job due to illness
Presenteeism• Impaired job performance and productivity while at work
Depression has huge impact on workplace productivity
*
*
*
*
0
10
20
30
40
50
(Missed work days) (Decreased effectiveness)
Per
cen
tag
e o
f p
atie
nts
PresenteeismPresenteeism
AbsenteeismAbsenteeism
No depressivesymptoms (n=4,387)
Acute depressive symptoms (n=652)
Chronic depressive symptoms (n=501)
Druss et al. Am J Psychiatry 2001; 158: 731–734*p<0.001 vs. no depressive symptoms
Factors that impair work functioning
Depressive symptoms• Fatigue and low energy• Insomnia• Concentration and memory
problems• Anxiety (especially social
anxiety)• Irritability
Medication side effects• Daytime sedation• Insomnia• Headache• Agitation/anxiety• Nausea and GI effects
Lam et al. CANMAT Working with Depression Program, 2008
Is real-life functionality the new goal of treatment?
Relapse is very Common
Euthymia
Symptoms
Syndrome
Remission
Response
Recovery – 6 months
Continuation treatment
Maintenance treatment
Relapse Recurrence
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What are the clinical milestones for treatment of depression?
• Onset of response (≥20% improvement from baseline) • Response (≥50% improvement from baseline)• Different grades of remission:
Wade et al. J Psychiatr Res 2009; 43: 568–575
6 monthsNo residual symptoms
No MADRS item >1Symptom-free remission
6 monthsCorresponds to CGI-S = 1
MADRS ≤5Complete remission
Defined as Reason Useful at
Remission MADRS ≤12Prospectively defined
8 weeks
Remission MADRS ≤10 Commonly used 8 weeks
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Response and Remission defined
Hamilton Depression Rating Scale (HAM-D): 17 Items, Total Score 0 - 52
15
7
Response 50% reduction from baseline HAM-D
score
Remission: HAM-D Score 7
Depression (Major Depressive Disorder)
References:1. Frank E. Conceptualization and rationale for consensus definition terms in MDD, Arch Gen Psych. 1991; 48:851-855.
HAM-D17 Scores
30
Is remission the optimal outcome?
• Remission (as measured by symptom scales) is an important target for treatment
• Residual symptoms are predictors of relapse, chronicity and suicidality
• There are various remission criteria
• But, does remission = ‘health’ or functional recovery?
‘Health’ is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.
World Health Organization
Preamble to the Constitution of the World Health Organization, 7 April 1948
31
Many depressed patients are still depressed.
References:
1. Nierenberg AA, et al. J Clin Psychiatry. 1999:60(suppl 22):7-11.
2. O’Reardon JR, et al. Psychiatr Ann. 1998;28:633-640.
3. Lynch ME. J Psychiatry Neurosci. 2001;26(1):30-36.
Depressed patients continue to have needs that are not being fully addressed1
• Depressed patients present with emotional and physical symptoms.
• Approximately 30% of depressed patients achieve remission in clinical trials2*
• Up to 70% of patients who respond fail to remit2*
• Incomplete relief from symptoms may increase the risk of relapse2,3
• Emotional and physical symptoms may delay achieving remission.
*In antidepressant clinical drug trials.
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‘Feeling better’ ‘Doing better’vs
Remission does not always translate into functional outcomes
p=ns
Per
cen
tag
e o
f p
atie
nts
ac
hie
vin
g
rem
issi
on
(M
AD
RS
≤12
)
Imp
rove
me
nt
in S
hee
han
D
isa
bil
ity
Sc
ore
*
Escitalopram20 mg/day
Duloxetine60 mg/day
100
70
60
50
40
30
20
10
0
90
80
*p<0.05 vs. duloxetine
Escitalopram20 mg/day
Duloxetine60 mg/day
16
12
10
8
6
4
2
0
14
Adapted from Wade et al. Curr Med Res Opin 2007; 23: 1605–1614
Remission (MADRS ≤12) at week 24
Improvement in Sheehan Disability Score at week 24
33
What is a ‘good enough’ outcome for the treatment of depression?
Physician perspective: Signs Adverse events
Patient perspective: Symptoms Adverse events Wellbeing Quality of life Functioning Economic aspects
Society perspective: Functioning Economic aspects
34
Factors identified by depressed outpatients as very important in defining remission
In rank order: Presence of positive mental health
(e.g. optimism, self-confidence) Feeling like your usual, normal self Return to usual level of functioning at work, home
or school Feeling in emotional control Participating in, and enjoying, relationships with
family and friends Absence of symptoms of depression
Zimmerman et al. Am J Psychiatry 2006: 163 (1): 148–150
35
Sick leave – the patient’s perspective
Potential benefits Removal from occupational stresses and under-performing More time and opportunity to engage in activities conducive to
recovery
Drawbacks Patient inactivity, retreats to bed Isolation, without the usual social contacts afforded by the
workplace Development of a secondary anxiety pattern whereby patient
becomes more apprehensive about returning to work The longer the disability leave, the less likely it is that the patient
will ever return to gainful employment
Bilsker et al. Can J Psychiatry 2006; 51 (2): 76–83
36
Impact of depression on sick leave duration
Naturalistic study in a working population (Austria) Days on sick leave 3 months prior to and 3 months
during escitalopram treatment were compared in 2,325 patients (949 men and 1,376 women)
Winkler et al. Hum Psychopharmacol 2007; 22 (4): 245–251; Buist-Bouwman et al. Acta Psychiatr Scand 2006; 113 (6): 492–500
37
Number of sick days – a distribution
Winkler et al. Hum Psychopharmacol 2007; 22 (4): 245–251
n=754
Days on sick leave in 3 months during escitalopram treatment
Sick leave was due to psychiatric morbidity
Days on sick leave in 3 months prior to escitalopram treatment
p<0.001
Number of sick days
1–2 3–5 6–10 11–15 16–20 21–30 >30
15
12
9
6
3
0
Pat
ien
ts (
%)
wit
h s
ick
day
s
38
How to optimize pharmacotherapy for depressed workers
• Choose appropriate treatments
• Enhance adherence
• Monitor outcomes
• Manage non-responders
Lam et al. CANMAT Working with Depression Program, 2008
Influence of antidepressants on functional outcomes
40
Winkler et al. Hum Psychopharmacol 2007; 22 (4): 245–251
Effect of Cipralex® on functional outcome – open-label results
Percent of Canadian patients on medical leave after escitalopram treatment (n=641)
Chokka et al. Canadian J Diagnosis May 2008: 105– 112
Sick days in Austrian patients (n=2,387) treated with escitalopram
Num
ber o
f sic
k da
ys
Baseline 3 Months0.0
2.0
4.0
6.0
8.0
10.0
12.0
* p<0.001
11.0
5.4*
0
2
4
6
8
10
12
14
16
Baseline Week 2 Week 6 Week 12Week 24
Perc
ent o
f pati
ents
on
med
ical
leav
e
41
Escitalopram significantly improves daily living
Baseline Sheehan Disability Scores: work=6.49, social=6.97, family=6.81; LOCF Wade et al. Curr Med Res Opin 2007; 23 (7): 1605–1614
Week 8 Week 24 Week 8 Week 24 Week 8 Week 24
Occupational Social Family
Ch
ang
e fr
om
bas
elin
e in
SD
S s
core
0
-1
-2
-3
-4
-5
* **
Escitalopram 20 mg/day
*p<0.05 vs duloxetine
Duloxetine 60 mg/day
42
Take Home Message
• ‘Symptom free’ is a realistic remission outcome, however success rates differ among antidepressants
• Recovery of functionality – especially work functioning – is important to patients (and should be for clinicians)
• Remission of symptoms is not always associated with functional improvement
• Escitalopram superiorly improves daily living and functional outcomes compared to other SSRIs & SNRIs.