Targeting what matters most for patients with depression: Strategies for promoting full functional recovery

Major depression is a common and serious condition with symptoms across domains and being very different from one patient to another. There has been an evolution in treatment targets for depression beyond response and remission as measured using depression rating scales such as HAM-D or MADRS, toward considering the full range of symptoms across emotional, cognitive and physical domains. This is critical for helping patients gain from treatment what matters most to them, mainly returning to their usual level of daily functioning, and experiencing productive and meaningfulness lives. However, targeting full functional recovery in depression remains challenging in clinical practice.

We need to focus on the individual patient to support early and effective intervention in depression

Eduard Vieta, Professor of Psychiatry at the University of Barcelona, highlighted the early detection and effective treatment of first-episodes as the alpha and omega for reducing the risk of chronicity, increase the chance of functional recovery, and countering the neurobiological processes that underlie the progression of depression. For example, fMRI studies suggest not only a direct association between length of illness and volume of the hippocampus but also that the largest volume reduction happens with the first few depressive episodes, giving a window of time to potentially intervene in the very beginning of illness.1,2 Prof Vieta also highlighted that while clinical response is a strong predictor of functional outcomes, emerging evidence suggests that impaired cognitive performance, which often persists even during remission, may also drive functional impairment.3,4

According to Prof Vieta, early and effective intervention relies on several focused strategies, including the selection of treatments that consider the patient’s individual symptom profile across domains, and measurement-based care to support ongoing evaluation and eventual modification following treatment initiation, for example using e-health tools.5 Prof Vieta emphasized the importance of adopting a patient-centered approach based on a shared understanding between patient and health-care professionals of the overall treatment targets.

 

Depression scales: Are we asking the right questions?

Koen Demyttenaere, Professor of Psychiatry in the Faculty of Medicine at the University of Leuven in Leuven, Belgium, continued by elaborating on the importance of a patient-focused approach when formulating treatment targets and evaluating treatment outcomes.6,7

Studies show that expectations of treatment can differ dramatically between physicians and patients and that these differences can significantly influence treatment outcome8, 9. To overcome this challenge, Prof Demyttenaere highlighted the importance of considering if the measurement methods and tools used for assessing progress reflect what matters most for the patients.

The expert presented recent data obtained using the Leuven Affect and Pleasure Scale (LAPS), suggesting that while physicians may focus on the absence of negative affect when assessing recovery, patients consider the broader experience of the full range of emotional functioning, hedonic tone, cognitive and overall functioning, and meaningfulness of life as important for considering themselves in recovery.10 Physicians and patients may hence not be on the same page in their understanding of treatment success. The LAPS may provide a means of assessing the dimensions beyond mood symptoms that patients consider important.

 

Getting back to work does not equal functioning at work

Pratap Chokka, Clinical Professor of Psychiatry at the University of Alberta concluded the session with discussing the challenges faced by working patients with depression, the type of impairments that are particularly relevant for their work functioning, and strategies to assess and improve functional outcomes for this group of patients.

Highlighting the intimate relation between work functioning and mental health, Prof Chokka pointed out that many patients with depression face the problem not only of having to take time off work - absenteeism - but also experience reduced productivity when at work, presenteeism. Prof Chokka went on to explain that addressing cognitive symptoms plays a particularly important role in restoring work performance. Recent data from the AtWoRC study,11,12 an observational, 52-week Canadian study in employed patients, found that improving the cognitive symptoms of depression was associated with improved work functioning, reduction in absenteeism, decreased health-care utilization, and economic savings, as well as improved overall functioning. He concluded the session with the key message that treatment should focus not only on helping patients get back to work, but also aim to restore their functioning at work.

 

Educational financial support for this ECNP Satellite symposium was provided by H. Lundbeck A/S.

Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.

References

1. MacQueen GM et al. Proc Natl Acad Sci USA 2003; 100: 1387-92.

2. MacQueen GM et al. Biol Psychiatry 2008; 64: 880-3.

3. Evans VC et al. J Clin Psychiatry 2014;75:1359-70

4. Rock PL et al. Psychol Med 2014; 44: 2029-40.

5. Guo T, Xiang YT, Xiao L et al. Am J Psychiatry 2015; 172(10): 1004-1013.

6. Carpiniello B et al. Acta Psychiatr Scand 1997; 96: 235-41.

7. Zimmerman M et al. Am J Psychiatry 2006; 163: 148-50.

8. Demyttenaere K, Donneau AF, Albert A et al. J Affect Disord 2015; 174: 390-396.

9. Demyttenaere K, Donneau AF; Albert et al. J Affect Disord 2015; 174: 372-377.

10. Demyttenaere K Mortier P, Kiekens G et al. CNS Spectr 2019; 24: 265-74.

11. Chokka P, Bougie J, Rampakakis E et al. CNS Spectr. 2018; 24(3), 338-347.

12. Chokka P, Bougie J, Proulx J et al. CNS Spectr. 2019; 25, 1-12.

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