1

Scientific Committee• Pratap Chokka, MD, FRCPC (Edmonton, AB) – Chair• Marie-Claude Garant, MD, MCFP (Mirabel, QC)• Tom Janzen, MD, CCFP (London, ON)• Mona Lee, MD, CCFP (Vancouver, BC)

Presenter disclosure

• Name: Pratap Chokka, MD, FRCPC

• Relationships with commercial interests: Grants/research support: Janssen, Lundbeck Speakers bureau/honoraria: Bristol-Myers Squibb, Janssen,

Shire, Purdue, Lundbeck, Pfizer

Disclosure of commercial support

• This program has received financial support from Lundbeck Canada Inc. in the form of an educational grant

• This program has received in-kind support from Lundbeck Canada Inc. in the form of logistical support

• Potential for conflict(s) of interest: The speakers have received an honorarium from The College of

Family Physicians of Canada to present this program Lundbeck Canada Inc. developed and distributes the following

products that may be discussed in this program: (i) citalopram (Celexa®); (ii) escitalopram (Cipralex®, Cipralex MELTZ®); and (iii) vortioxetine (TRINTELLIX®)

Mitigating potential bias

• Information/recommendations in the program are evidence- and/or guidelines-based; opinions of the speaker will be identified as such

• The program was developed and reviewed by a steering committee composed of independent third-party experts responsible for vetting the program’s needs assessment and content development to ensure accuracy and fair balance

• The program was reviewed by selected CFPC reviewers and approved for submission for accreditation

• The speaker completed the CFPC Mainpro+® Declaration of Conflict of Interest form evidencing compliance with Mainpro+®

requirements, a requisite for this program to be given accredited status

• Various competitor brands are presented to mitigate potential bias

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Disclaimer

• The views expressed during this presentation are the personal views of the presenter and do not necessarily reflect the opinions and positions of Lundbeck Canada Inc.

• This educational program may contain information about drugs or indications that have not been authorized for marketing in Canada

Certification

This Group Learning program has been certified by the College of Family Physicians of Canada and the Québec College of Family Physicians for up to 1.0 Mainpro+ credits (Category 1 for non-CFPC members).

Presenter: Dr. Valérie Tourjman

Presenter disclosure

• Name: Valérie Tourjman, MDCM, FRCPC (Montreal, QC)

• Relationships with commercial interests: Has received research and education grants, served on

advisory boards, or acted on speaker bureaus for: BMS, Janssen, Lundbeck, Pfizer, Purdue, Shire, Sunovion, Valeant

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Learning objectives

After completing this educational activity, participants will be better able to:

01

02

03

Describe the prevalence of MDD in working individuals and the burden of the disorder in the workplace

Explain current management approaches to MDD to help improve workplace functioning and productivity

Assess new evidence linking improvements in cognitive symptoms of MDD with better functioning and workplace productivity

Poll the audience!

A

B

C

D

Please hold up your selected response card

Polling question 1

What percentage of individuals with depression are working full time and are fully functioning* at work?

40%

23%

30%

17%

*Full functioning: an employee’s ability to perform all regular work duties

A

B

C

D

Extent to which depressed Canadians are able to function at work

40% 20%

23%17%

310,000 Canadians were unable to work

due to their depression

266,100 Canadiansworked part-time

because their depression prevented them from

working full time

532,200 Canadians with depression were

able to work full time, but with reduced

functioning

222,200 Canadians with depression were fully functioning

at work

Southerland G, Stonebridge C. The Conference Board of Canada; 2016.

More than 1 million employed Canadians worked during a depressive episode in the past year (2012)

4

Depression can affect one’s performance and functioning at work

Southerland G, Stonebridge C. The Conference Board of Canada; 2016.

Absence from work (due to depression)

About 205 hours or 25 days lost in a

given year

AbsenteeismComing to work while

depressed and performing with reduced productivity or reduced functioning

About 487 hours or 60 days lost in a

given year

PresenteeismBetter treatment of depression to improve

functioning could potentially boost the

Canadian economy by about $32 billion a year

Polling question 2

What is a principal reason for reduced work function and performance as a result of depression?

Insomnia

Fatigue

Cognitive difficulties

Depressed mood

A

B

C

D

Cognitive dysfunction associated with presenteeism and productivity loss

• Cross-sectional observational study of 312 outpatients with MDD in South Korea Irrespective of depression severity, patients with more severe cognitive dysfunction

reported worse work-related productivity outcomes More severe cognitive dysfunction was the only factor significantly associated with

higher presenteeism

Kim JM, et al. Psychiatry Res. 2016;239:353-61.

6%

25%30%33%

71% 72%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Absenteeism Presenteeism Overall work productivity loss

Déf

icit

moy

en, %

Milder cognitive dysfunction (PDQ-D <13) More severe cognitive dysfunction (PDQ-D >43)

One of the principal reasons for reduced work performance in depression

Southerland G, Stonebridge C. The Conference Board of Canada; 2016.Clark M, et al. Expert Rev Pharmacoecon Outcomes Res. 2016;16(4):455-63.

Woo YS, et al. Clin Psychopharmacol Neurosci. 2016;14(1):1-16.

Cognitive difficulties are a principal reason for reduced work performance as a result of depression

For patients with major depressive disorder, an improvement in work functioning can be as important as remission

5

Felix

• Married, 36 years old• Three children, ages 2, 4, and 7 years• Employed full time• No history of MDD or other mental

health disorders• No family history of mental health

disorders• Not currently taking any medications• Non-smoker

Reason for physician visit

• Felix’s wife has insisted he see the family GP because, in recent months, he is irritable with her and their children

“I’ve been really impatientand tired, and I have a hard

time sleeping. I don’t recognize myself anymore. I just feel very

stressed… But I’m sure it’s normal, it's just work pressure.”

“He always brings his work home with him and never spends

any time with us. Then he takes his anger out on me and the kids. I see him struggling a lot, he seems down,

this just doesn’t seem like him.”

Felix: Assessing for symptoms of MDD

Felix’s PHQ-9 score: 20

20

Felix Sep 19/17

PHQ-9, Patient Health Questionnaire, 9-item version.

PHQ-9 total score interpretation:≥10: Possible diagnosis of MDD0-4: Minimal to no depression5-9: Mild depression10-14: Moderate depression15-19: Moderately severe depression≥20: Severe depression

MDD is a multidimensional illness – with functional consequences

Adapted from: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. 2013.

Bender A. Canadian J Diagnosis. 2011;28(1):13-20.Lam RW, et al; CANMAT Depression Work Group. Can J Psychiatry. 2016;61(9):510-23.

Cognitive

Trouble concentrating, trouble making decisions,

forgetfulness, trouble paying attention

? ? ?

Physical

Tiredness, pain, sleep disturbance,

weight and appetite loss/gain Emotional

Sadness,lack of motivation/pleasure,

anxiety, irritability

Symptoms

Work impairment: loss of productivity and efficiency,

increased risk of errors,poor decision-making

Self-restricted activities,neglect of duties,

reduced vigilance to tasks

Functional Consequences

Inappropriate emotions,conflict, avoidance, and withdrawal

Full Functional Recovery

6

Treatments that address ALL symptoms

(emotional, physical,and cognitive) can

help achieve a return toFULL FUNCTION

2016 Canadian MDD guidelines: Treat to full functional recovery

Long-term goalsMaintenance phase of treatment

Prevention of recurrence

Return to full function and quality of life

6-24MONTHS

or longer

Short-term goalsAcute phase of treatment

Restoring function

Remissionof symptoms

8-12WEEKS

Lam RW, et al; CANMAT Depression Work Group. Can J Psychiatry. 2016;61(9):510-23.

The link: Cognitive dysfunction and overall functioning

20162014201120102008

1. Jaeger J, et al. Psychiatry Res. 2006;145(1):39-48; 2. Buist-Bouwman MA, et al. Acta Psychiatr Scand. 2008;118(6):451-8; 3. Conradi HJ, et al. Psychol Med. 2011;41(6):1165-74; 4. Baune BT, et al. Psychiatry Res. 2010;176(2-3):183-9;

5. Godard J, et al. Psychiatry Res. 2011;190(2-3):244-52; 6. Evans VC, et al. J Clin Psychiatry. 2014;75(12):1359-70;7. Lam RW, et al; CANMAT Depression Work Group. Can J Psychiatry. 2016;61(9):510-23.

2006

Cognitive dysfunction strongly associated with impaired life functioning

in MDD, even when emotional symptoms

have improved1

Cognitive dysfunctionis prevalent and

often persists in MDD;3,4

strongly associatedwith unemployment4

Systematic review of 10 studies concludes that

cognitive symptoms appear to be broadly associated with

functional impairment6

~50% of impaired role functioning in MDD mediated by

cognition and feelings of embarrassment,

independent of comorbidities2

Canadian guidelines state cognitive dysfunction associated with significant impact on daily functioning

and quality of life7Cognitive dysfunction significantly correlated

with functional impairment, particularly at work5

Symptom rating scales in MDD at baseline and follow-up

Rating scale Rater Totalitems

Emotional symptoms

Physical symptoms

Cognitive symptoms

HAM-D Physician 21 8 11 2

HAM-D7 Physician 7 5 2 0

MADRS Physician 10 7 2 1

PHQ-9 Patient self-report 9 5 3 1

DSM-5, Diagnostic and Statistical Manual of Mental Disorders, 5th edition; HAM-D, Hamilton Rating Scale for Depression; HAM-D7, Hamilton Rating Scale for Depression, 7-item version; MADRS, Montgomery–Åsberg Depression Rating Scale; PHQ-9, Patient Health Questionnaire, 9-item version.

Traditional rating scales measure a cross-section of DSM-5 symptoms

Functional impairment rating scales in MDD at baseline and follow-up

Rating scale Rater Description

LEAPS Patient self-report

A 10-item scale that helps to assess how patients are functioning at work

SDS Patient self-report

A 5-item tool that helps to assess functional impairment in 3 inter-related domains: work/school, social life, and family life

WHODAS 2.0Physician or patient self-report

Covers 6 domains of functioning: cognition, mobility, self-care, getting along with others, life activities, and participation in the communityAvailable in 12-item (~5 minutes to complete) and 36-item (~20 minutes to complete) versions

LEAPS, Lam Employment Absence and Productivity Scale; MDD, major depressive disorder;SDS, Sheehan Disability Scale; WHODAS, World Health Organization Disability Assessment Schedule.

7

Felix: Assessing function

Felix’s SDS: markedly disrupted work and family/home life, moderately disrupted social life, and many days unproductive

SDS, Sheehan Disability Scale.

FelixSDS

0

5

Sep 19/17

Probing for more information from Felix

• Irritable most of the time• Everything and everyone gets on his nerves• Takes a long time to fall asleep, usually later than

1 a.m.; wakes at least twice per night• Feels discouraged at times• Feels quite sad but not crying• Less of an appetite but not losing weight• Often has headaches and dyspepsia• No longer experiences any pleasure in his life

No longer interested in sex

No longer interested in his hobbies (playing guitar, organizing suppers at home with friends/family, renovating his home)

No longer interested in his work

• Wants to isolate himself; has given up on everything

More information from Felix…

• Forgets details at work; recently his errors resulted in lost revenue on 2 occasions His supervisor has commented on his performance;

he fears for his job, which makes him anxious

• Has poor concentration when reading, making decisions, and managing meetings

• Loses track of his thoughts, causing him distress

• Is afraid of making mistakes so he works slowly and re-checks his work, causing lost time and impaired work performance To compensate, he brings work home, which is hurting

his family life

• Drinks wine every night because it makes him feel calm; before, only had wine on weekends with his wife

After assessing all MDD domains and function…

• Felix identified the most burdensome problems impairing his overall and work-specific functioning:

Emotional domain: Irritable with family and work colleagues, doesn’t care about work or hobbies

Physical domain: Sleep problems, headaches, dyspepsia

Cognitive domain: Trouble concentrating, difficulty remembering and planning, struggling to make decisions

8

Polling question 3

Do you consider a sick note a part of the treatment plan for a working patient?

Yes

Sometimes

No

A

B

C

Sick notes and disability forms

• Provide opportunity for physician to advise patient on strategies to remain in or return to work, which is a measure of treatment success A person with MDD should not automatically be advised time off work Some patients with MDD may not be able to work in their specific position

but can be accommodated to work in another capacity; i.e., employers can adjust, and employees – even while depressed – can work in another role

Some individuals who are prescribed sickness absence are at risk of losing work habits, motivation, and work relationships

Length of absence is a risk for physical and mental deterioration, psychological distress, social exclusion, loss of income, etc.

The longer a patient is off work, the lower the chances of returning: 3 to 6 months off – less than 50% ≥12 months off – less than 20%

Dunstan DA. Aust Fam Physician. 2009;38(1-2):61-3.Waddell G, Burton AK. Is Work Good for Your Health and Well-Being? London, UK: The Stationery Office; 2006.

Wynne R, McAnaney D. Employment and Disability: Back to Work Strategies. Dublin, UK: European Foundation for the Improvement of Living and Working Conditions; 2004.

Remaining in work or returning as soon as possible is therapeutic:helps to promote recovery, full participation in society, independence,

reduce poverty, and improve quality of life and well-being

The sick note is an intervention

• If you decide the depressed patient requires time off work, make an endpoint – time should be limited Manage patient expectations with respect to

duration of time off work They should begin to see symptom improvement

within 2 weeks off work (as with medication)• Patient must remain active

E.g., exercise, therapy, etc. Can’t stay in bed all day

• Importance of regular monitoring and follow-up (as needed) for symptoms and function Work closely with Employee Assistance Program,

disability case manager, etc. for safe return to work

• Set clear goals with the patient Consider what support the patient needs to return to full function

(pharmacotherapy, psychotherapy, etc.) Recognize what the patient can do, rather than not do

“Sick Note”

Foley M, et al. Eur J Gen Pract. 2012;18(2):92-9.Macdonald S, et al. BMC Fam Pract. 2012;13:82.Nilsing E, et al. BMC Public Health. 2012;12:907.

Sylvain C, et al. BMC Fam Pract. 2016;17:71.

Setting goals with Felix…

• Take a few minutes with Felix to discuss his diagnosis and what to expect in the short, medium, and long term as he begins his path towards recovery

• Listen actively and explore his preferences and understanding; build an alliance with the patient; be supportive and empathetic of his feelings Felix initially resistant to diagnosis and treatment,

but opens up to the idea of support Manage expectations in relation to his ability to

continue working, etc.

• Provide guidance and outline next steps Importance of appropriate therapeutic interventions,

maintaining appropriate work-life balance and self-care

O’Brien K, et al. Fam Pract. 2008;25(1):20-6.Nilsen S, et al. Scand J Prim Health Care.

2015;33(1):40-6.

9

Felix’s treatment plan

• Pharmacological treatment

• Psychoeducation, counselling, cognitive behavioural therapy (CBT)

• Exercise (at least 3 times/week)

• Sleep hygiene

• Healthy diet, avoid drugs and alcohol

• Provide resources on MDD and self-care management

• Re-check in 2 to 4 weeks (symptom and functional assessment)

Take a holistic, individualized approach to the treatment plan

Polling question 4

Which first-line antidepressant do you think could help improve Felix’s overall functioning?

SNRI (e.g., desvenlafaxine)

SSRI (e.g., sertraline)

Multimodal (e.g., vortioxetine)

Other

A

B

C

D

Evidence-based selection of antidepressantsPresenter: Dr. Pratap Chokka

Considerations when selecting an antidepressant

Patient factors

• Clinical features and symptoms/dimensions of depression

• Comorbid conditions

• Response and side effects from previous use of antidepressants

• Patient preference

Medication factors

• Comparative efficacy –ability of agent to improve symptoms and functioning

• Comparative tolerability –potential side effects (sexual dysfunction, daytime sleepiness, weight gain, etc.)

• Potential interactions with other medications

• Cost and availability

Adapted from: Lam RW, et al; CANMAT Depression Work Group. Can J Psychiatry. 2016;61(9):510-23.

10

Approved May 2015• SNRI (that has greater selectivity for

norepinephrine than for serotonin)• Second-line recommendation

Levomilnacipran (Fetzima)SNRI

Antidepressants newly approved since 2009 Canadian MDD Guidelines

Approved October 2014• Multimodal (2 modes of action:

reuptake inhibition + receptor activity)• First-line recommendation

Vortioxetine (Trintellix)Multimodal

Approved September 2015• Multimodal (2 modes of action:

reuptake inhibition + receptor activity)• Second-line recommendation

Vilazodone (Viibryd)

Multimodal

Adapted from: Kennedy SH, et al; CANMAT Depression Work Group. Can J Psychiatry. 2016;61(9):540-60.

First-line antidepressants with different mechanisms of action have similar efficacy in treating mood symptoms of MDD

Arrows indicate increases in monoamines via other mechanisms (i.e., receptor activities).

+++++++++

+++++

+

0.1-11-1010-100100-1,0001,000-10,000

Ki (nM)

SSRIs 5-HT NE DA

Citalopram (Celexa) ++++ +

Escitalopram (Cipralex) ++++ +

Fluoxetine (Prozac) ++++ ++ +

Fluvoxamine (Luvox) ++++ ++

Paroxetine (Paxil) +++++ +++ ++

Sertraline (Zoloft) +++++ ++ +++

SNRIs 5-HT NE DA

Desvenlafaxine (Pristiq) +++ + +

Duloxetine (Cymbalta) ++++ ++++ ++

Venlafaxine (Effexor) +++ + +

NaSSa 5-HT NE DA

Mirtazapine (Remeron) ↑↑ ↑↑

Receptor blocker: antagonist at 2, 5HT2A, 5HT2c, 5HT3

NDRI 5-HT NE DA

Bupropion (Wellbutrin) + ++

Multimodal 5-HT NE DA

Vortioxetine (Trintellix) ↑↑ ↑↑ ↑↑

Blocks 5HT transporter, antagonist at 5HT1D, 5HT3, and 5HT7Agonist at 5HT1A, partial agonist at 5HT1B

Ki values are gathered from multiple labs and presented as published in the Clinical Handbook of Psychotropic Drugs, 2009.

Adapted from: Virani AS, et al. Clinical Handbook of Psychotropic Drugs, 19th rev ed. 2012. Adapted from: Stahl SM. Stahl’s Essential Psychopharmacology, 3rd ed. 2008.

Kennedy SH, et al; CANMAT Depression Work Group. Can J Psychiatry. 2016;61(9):540-60.

Created by Tom Janzen, MD, CCFP

This chart is not intended to imply any specific difference in clinical efficacy or tolerability, but merely to highlight the fact that these antidepressants have mechanistic differences.

5-HT, 5-hydroxytryptamine (serotonin); DA, dopamine; Ki, inhibitor constant (binding affinity); NaSSa, noradrenergic and specific serotonergic antidepressant; NDRI, norepinephrine-dopamine reuptake inhibitor; NE, norepinephrine; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor.

Antidepressants with efficacy in treating physical symptoms of MDD

Recommendations(level of evidence) Comments

Agomelatine (Level 1)Mirtazapine (Level 2)Quetiapine (Level 2)Trazodone (Level 2)Moclobemide (Level 3)

Beneficial effects on sleep must be balanced against potential for side effects (e.g., daytime sedation)

New Canadian MDD guideline recommendations to address sleep disturbances

Kennedy SH, et al; CANMAT Depression Work Group. Can J Psychiatry. 2016;61(9):540-60.

New Canadian MDD guideline recommendations to address somatic symptomsRecommendations(level of evidence) Comments

Duloxetine (pain) (Level 1)Other SNRIs (pain) (Level 2)Bupropion (fatigue) (Level 1)SSRIs* (fatigue) (Level 2)Duloxetine* (energy) (Level 2)

Few antidepressants have been studied for somaticsymptoms other than pain

Few comparative antidepressant studies for pain and other somatic symptoms

*Comparisons only with placebo.Agomelatine (greyed out) is not available in Canada.

Mirtazapine improved sleep quality of real-world outpatients with MDD

21.4%

14.0%

0%

5%

10%

15%

20%

25%

Mirtazapine (n=845) SSRIs/SNRIs (n=2,610)

Red

uctio

n ra

te, %

Reduction rate in global PSQI score from baseline to follow-up* in 3,455 outpatients with insomnia after treatment

†

*Average follow-up was 11 days. †P<0.001 vs. SSRIs/SNRIs.MDD, major depressive disorder; PSQI, Pittsburgh Sleep Quality Index; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor. Wang D, et al. Asia Pac Psychiatry. 2014;6(2):152-60.

11

Duloxetine improved painful physical symptoms associated with MDD

31.4%

20.9%

0%

10%

20%

30%

Duloxetine (n=523) Placebo (n=532)

Red

uctio

n ra

te, %

Reduction rate in average pain score (BPI) from baseline over8 weeks of treatment in MDD patients with at least moderate pain

†P<0.0001 vs. placebo.BPI, Brief Pain Inventory.

Robinson MJ, et al. Int Clin Psychopharmacol. 2013;28(6):330-8.Gaynor PJ, et al. Curr Med Res Opin. 2011;27(10):1849-58.Gaynor PJ, et al. Curr Med Res Opin. 2011;27(10):1859-67.

†

Antidepressants with efficacy in treating cognitive symptoms of MDD

Recommendations(level of evidence) Comments

Vortioxetine (Level 1)Bupropion (Level 2)Duloxetine (Level 2)SSRIs (Level 2)*Moclobemide (Level 3)

Limited data available on cognitive effects of other antidepressants and on comparative differences in efficacy

New Canadian MDD guideline recommendations to address cognitive dysfunction

Kennedy SH, et al; CANMAT Depression Work Group. Can J Psychiatry. 2016;61(9):540-60.*Comparisons only with placebo.

Differences exist between antidepressants’ effects in improving cognitive measures

-1.0

0.34 (0.17, 0.50)Vortioxetine (3 studies, n=728, P=0.0001)

-0.5 0.0 0.5 1.0

0.10 (-0.01, 0.22)Duloxetine (4 studies, n=714, NS)

0.22 (-0.34, 0.79)Paroxetine (1 study, n=23, NS)

0.02 (-0.28, 0.32)Citalopram (1 study, n=84, NS)

StudyStd. mean difference IV, random (95% CI)

Favours placebo Favours antidepressant

-0.02 (-0.61, 0.58)Phenelzine (1 study, n=28, NS)

0.01 (-0.57, 0.59)Nortriptyline (1 study, n=32, NS)

-0.12 (-0.51, 0.28)Sertraline (1 study, n=49, NS)

Rosenblat JD, et al. Int J Neuropsychopharmacol. 2015;19(2). pii:pyv082.

Pooled effect for placebo-controlled trials assessing the effect of antidepressants on psychomotor speed (DSST)

Antidepressants n=1,658; placebo n=875.CI, confidence interval; DSST, digit symbol substitution test; IV, inverse variance; NS, not significant; Std, standard.

Real-life Canadian data on the association between cognitive dysfunction and workplace productivity in MDD patients

• Assessment in Work productivity and the Relationship with Cognitive symptoms (AtWoRC) is an interventional, open-label, Canadian study

• Primary objective: To describe the association/correlation between change

from baseline to week 12 in patient-reported cognitive symptoms (PDQ-D-20) and work productivity loss (WLQ) in gainfully employed patients receiving vortioxetine for a major depressive episode

• N=196 (97 first treatment, 99 switch)

PDQ-D-20, Perceived Deficits Questionnaire-Depression, 20-item version; WLQ, Work Limitations Questionnaire.

Chokka P, et al. Presented at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR)

Annual International Meeting, May 20–24, 2017. Poster PMH11.

12

AtWoRC primary endpoint: Association between PDQ and WLQ productivity loss

Group n r P-valueFAS 196 0.633 <0.001First treatment 97 0.671 <0.001Switch 99 0.584 <0.001

Partial correlation between change in PDQ-D-20 and change in WLQ productivity loss from baseline to week 12 (OC)

AtWoRC, Assessment in Work productivity and the Relationship with Cognitive symptoms; CGI-S, Clinical Global Impression-Severity; FAS, full analysis set; OC, observed cases; PDQ-D-20, Perceived Deficits Questionnaire-Depression, 20-item version; QIDS-SR, Quick Inventory of Depressive Symptomatology-Self-Report; WLQ, Work Limitations Questionnaire.

FAS: All patients from the all patients treated set (APTS; all patients with a valid baseline assessment who took at least one dose of study medication) who attended at least one post-baseline study visit.Controlled for age, sex, baseline PDQ-D-20, baseline WLQ productivity loss, disease duration, and disease severity (baseline QIDS-SR, baseline CGI-S).

Patients who had improved cognitive function following treatment with vortioxetine also had improved workplace productivity

Chokka P, et al. Presented at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR)

Annual International Meeting, May 20–24, 2017. Poster PMH11.

Fewer missed work days with treatment

57%

22%

0%

10%

20%

30%

40%

50%

60%

Baseline (n=196) Week 12 (n=180)

Patients with missed work days at baseline and week 12 (FAS, OC)

12

7

0

2

4

6

8

10

12

14

Baseline (n=100) Week 12 (n=32)

If missed work, number of days at baseline and week 12 (FAS, OC)

FAS, full analysis set; OC, observed cases.

% Y

es

Mea

n #

of D

ays

Chokka P, et al. Presented at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR)

Annual International Meeting, May 20–24, 2017. Poster PMH11.

Next steps in Felix’s care and summaryPresenter: Dr. Valérie Tourjman

Polling question 5

Based on the data presented here and Felix’s symptoms, which first-line antidepressant do you now think could help improve Felix’s overall functioning?

SNRI (e.g., desvenlafaxine)

SSRI (e.g., sertraline)

Multimodal (e.g., vortioxetine)

Other

A

B

C

D

13

First-line non-pharmacological treatment options

Psychological treatments1

• Where feasible, combining psychological treatment (CBT or IPT) with antidepressant treatment is recommended Combined treatment may be superior to either treatment alone

• Behavioural activation interrupts patterns of inertia, avoidance, and social withdrawal linked to MDD

Complementary/alternative medicine treatments2

• Exercise: At least 30 minutes of supervised moderate-intensity exercise at least 3 times weekly for a minimum of 9 weeks

CBT, cognitive behavioural therapy; IPT, interpersonal therapy; MDD, major depressive disorder.

1. Parikh SV, et al; CANMAT Depression Work Group. Can J Psychiatry. 2016;61(9):524-39.2. Ravindran AV, et al; CANMAT Depression Work Group. Can J Psychiatry. 2016;61(9):576-87.

Consider incorporating one or more of these into the treatment plan when a patient is taking sick/disability leave from work

Summary and key take-home points

• More than 1 million employed Canadians were unable to work or worked below full capacity due to depression symptoms over the course of 1 year (absenteeism and presenteeism) Only 17% were fully functioning at work

• Remission of symptoms and return to full function and quality of life are key goals of treatment in MDD – right from the start This is relevant and important for all patients, especially those in the

workforce

• There is emerging evidence that improvement in cognitive symptoms of MDD results in change in overall functioning and work productivity To help patients achieve full functional recovery, select a treatment that is

effective at improving all symptom dimensions and overall functioning