2. 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
10. 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
11. Depression
20% of those with major depression have symptoms that
persist beyond 2 years
Keller et al., (1992) & Scot & Dicky (2003), B. J. Psychiat.
12. 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
13. Depression is an
Under-recognized Disorder
Stigma
Masked depression
Comorbid medical illness
Time constraints
Inadequate medical education
15. Cost of Depression
Who pays for it?
• Patients
• Families
• Health Care Provider
• System
16. Cost of Depression
to 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
17. Cost of Depression
Families
• Increased burden
• Patient being aloof from family causing more guilt and
anxiety
• Impaired relationship
• Increased risk of violence and neglect
18. Cost of Depression
Health Care Providers
• More likely to order work up
• Feelings of detachment
• May give up early
• Feelings of being a failure or not doing enough
23. ‘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
24. Depression has huge impact on workplace
productivity
*
*
*
*
0
10
20
30
40
50
(Missed work days) (Decreased effectiveness)
Percentageofpatients
PresenteeismAbsenteeism
No depressive
symptoms (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
25. 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
27. Relapse is very Common
Euthymia
Symptoms
Syndrome
Remission
Response
Recovery – 6 months
Continuation
treatment
Maintenance
treatment
Relapse Recurrence
28. 2
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 months
No residual
symptoms
No MADRS item >1
Symptom-free
remission
6 months
Corresponds to
CGI-S = 1
MADRS ≤5
Complete
remission
Defined as Reason Useful at
Remission MADRS ≤12
Prospectively
defined
8 weeks
Remission MADRS ≤10 Commonly used 8 weeks
29. 2
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. 3
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. 3
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.
32. 3
‘Feeling better’ ‘Doing better’vs
Remission does not always translate into
functional outcomes
p=ns
Percentageofpatientsachieving
remission(MADRS≤12)
ImprovementinSheehan
DisabilityScore
*
Escitalopram
20 mg/day
Duloxetine
60 mg/day
100
70
60
50
40
30
20
10
0
90
80
*p<0.05 vs. duloxetine
Escitalopram
20 mg/day
Duloxetine
60 mg/day
16
12
10
8
6
4
2
0
14
Adapted from Wade et al. Curr Med Res Opin 2007; 23: 1605–16
Remission (MADRS ≤12)
at week 24
Improvement in Sheehan
Disability Score at week 24
33. 3
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. 3
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. 3
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–
36. 3
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. 3
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
Patients(%)withsickdays
38. 3
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
40. 4
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
Numberofsickdays
Baseline 3 Months
0.0
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
Percentofpatientsonmedicalleave
41. 4
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
ChangefrombaselineinSDSscore
0
-1
-2
-3
-4
-5
* *
*
Escitalopram 20 mg/day
*p<0.05 vs duloxetine
Duloxetine 60 mg/day
42. 4
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.
Editor's Notes
The morbidity costs associated with depression in the workplace are derived from traditional research, including costs arising from workplace absenteeism of depressed employees, as well as reductions in workplace productivity during the employees’ episodes of depression1
Up to 15% of patients with MDD severe enough to require hospitalization eventually die of suicide.2 This high mortality rate necessitates the accurate identification and immediate treatment of patients experiencing MDD
Depression is associated with direct and indirect costs that place a significant burden on society1
MDD, if left untreated, significantly worsens health and functioning, giving rise to physical complaints and increased use of health care resources3
Sources:
1.Greenberg PE, et al. J Clin Psychiatry. 1993;54:405-418.
2.Depression Guideline Panel. Depression in Primary Care: Volume 1. Detection and Diagnosis. Clinical Practice Guideline, Number 5. AHCPR publication no. 93-0550. April 1993.
3.Henk HJ, et al. Arch Gen Psychiatry. 1996;53:899-904.
DISCUSSION NOTES:
Lost productivity while at work when unwell defines presenteeism
Self assessment of productivity has been shown to compare with assessment by supervisor even in depressed workers
QoL scales were the first scales used to assess functioning in mentally ill patients
GAF while imperfect is widely used, especially by insurance companies.
Self assessment presenteeism scales can be used by GPs by providing them to their working depressed patients. The WAPS will be discussed a little later in the presentation.
Reference:
Sanderson & al. Which presenteeism measures are more sensitive to depression and anxiety. J affective disorder 2006 Dec 5
*P&lt;0.001 vs no depressive symptoms group. 6,239 employees of 3 major US corporations
Missed work days=self report of 1 days missed from work due to health in past 4 weeks.
Decreased effectiveness=self-reported score below median for nondepressed employees.
Incident depressive symptoms=present in 1995 only.
Chronic depressive symptoms=present in both 1993 and 1995.
Druss BG, et al. Am J Psychiatry. 2001;158:731-734.
DISCUSSION NOTES:
Some symptoms and side effects have greater impact on work functioning than others.
Fatigue is often associated with poor sleep (insomnia), as is hypersomnia and daytime sedation. GI symptoms can impair daytime work performance. Daytime sedation is a particular concern in safety-sensitive occupations.
Anxiety is particularly important, given how common a symptom it is.
DISCUSSION NOTES:
It would be misleading to conclude that remission rates translate into functional outcomes. Despite equivalence in remission rates using conventional measures (i.e., the MADRS score) in this study comparing escitalopram and duloxetine, scores using functional rating scales do not suggest equivalence between these agents.
These findings underline the importance of measuring not only traditional efficacy and tolerability parameters in clinical studies, but also functional outcomes that describe how the patient is doing.
Marie Jahoda, 1980 : “work provides structure, meaning and an opportunity for social interaction”
DISCUSSION NOTES:
Some symptoms and side effects have greater impact on work functioning than others.
Fatigue is often associated with poor sleep (insomnia), as is hypersomnia and daytime sedation. GI symptoms can impair daytime work performance. Daytime sedation is a particular concern in safety-sensitive occupations.
Anxiety is particularly important, given how common a symptom it is.
DISCUSSION NOTES:
The aim of this observational study was to evaluate the effectiveness of escitalopram in a naturalistic sample of employed people with mood and anxiety disorders.
Can treatment improve absences and productivity? Yes, as this slide shows: patients treated with escitalopram for 3 months had an average reduction of almost 6 sick days per patient, a significant benefit to both patients and employers.
DISCUSSION NOTES:
Some symptoms and side effects have greater impact on work functioning than others.
Fatigue is often associated with poor sleep (insomnia), as is hypersomnia and daytime sedation. GI symptoms can impair daytime work performance. Daytime sedation is a particular concern in safety-sensitive occupations.
Anxiety is particularly important, given how common a symptom it is.