Improving Improving Outcomes in Major Depression: … · Improving Improving Outcomes in Major...

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Improving Improving Outcomes in Major Depression: Outcomes in Major Depression: The The Impact of Cognitive Dysfunction mpact of Cognitive Dysfunction The The Impact of Cognitive Dysfunction mpact of Cognitive Dysfunction ”Major depression effects our friends, our ”Major depression effects our friends, our neighbors and our patients neighbors and our patients- it robs us of who it robs us of who we are and our ability to cherish the ones we we are and our ability to cherish the ones we we are and our ability to cherish the ones we we are and our ability to cherish the ones we hold most dearly hold most dearly.” .” Greg Mattingly, MD Associate Clinical Professor, Washington University President Midwest Research Group President, Midwest Research Group

Transcript of Improving Improving Outcomes in Major Depression: … · Improving Improving Outcomes in Major...

Improving Improving Outcomes in Major Depression: Outcomes in Major Depression: The The IImpact of Cognitive Dysfunction mpact of Cognitive Dysfunction The The IImpact of Cognitive Dysfunction mpact of Cognitive Dysfunction

”Major depression effects our friends, our ”Major depression effects our friends, our neighbors and our patientsneighbors and our patients-- it robs us of who it robs us of who we are and our ability to cherish the ones wewe are and our ability to cherish the ones wewe are and our ability to cherish the ones we we are and our ability to cherish the ones we hold most dearlyhold most dearly.”.”

Greg Mattingly, MDAssociate Clinical Professor, Washington University President Midwest Research GroupPresident, Midwest Research Group

Top 3: Sleep, mood and concentrationTop 3: Sleep, mood and concentrationPrevalence of Symptoms During MDD Episodes Prevalence of Symptoms During MDD Episodes Prevalence of Symptoms During MDD Episodes Prevalence of Symptoms During MDD Episodes

100%20%0% 80%60%40%

Depressed mood

Sleep problems

Appetite problems

Sleep problems

Trouble thinking

Thoughts of death

• 13-year NIMH Study of 1,920 Individuals in the Baltimore Epidemiologic

Tiredness

Lost interest

Worthlessness

Thoughts of deathBaltimore Epidemiologic Catchment Area

Slowness/restlessness

Worthlessness

Chen LS, et al. Am J Psychiatry. 2000;157(4):573-580.

Sadness, Depression and Recovery:Reciprocal Limbic-Cortical Function and Mood

Mayberg HS et. al. Am J Psychiatry 156: 675-682, 1999.

Most Patients Fail to Achieve RemissionMost Patients Fail to Achieve RemissionMost Patients Fail to Achieve RemissionMost Patients Fail to Achieve RemissionSequenced Treatment Alternatives to Relieve Depression Sequenced Treatment Alternatives to Relieve Depression

((STAR*D)STAR*D)

2,876 patients with MDD treated in primary care and psychiatric 2,876 patients with MDD treated in primary care and psychiatric settingssettings

–– 80% of patients had chronic or recurrent depression80% of patients had chronic or recurrent depression FirstFirst--line treatmentline treatment FirstFirst--line treatmentline treatment

–– Flexible dose of citalopram for up to 14 weeks (mean dose 42 mg/day)Flexible dose of citalopram for up to 14 weeks (mean dose 42 mg/day)

Remission rate28%

Response rate47%

STAR*D, Sequenced Treatment Alternatives to Relieve Depression; STAR*D, Sequenced Treatment Alternatives to Relieve Depression; MDD, major depressive disorder; SSRI, selective serotonin reuptake MDD, major depressive disorder; SSRI, selective serotonin reuptake

T i di MH t lT i di MH t l A J P hi tA J P hi t 2006 163 282006 163 28 4040inhibitor.inhibitor. Trivedi MH, et al. Trivedi MH, et al. Am J Psychiatry.Am J Psychiatry. 2006;163:282006;163:28--40.40.

Depressive symptoms persist during periods of remission and Depressive symptoms persist during periods of remission and subsequent depressive episodessubsequent depressive episodessubsequent depressive episodessubsequent depressive episodes

Mean proportion of time DSM-IV symptoms are present during 3-year follow-up period (n=267)

Lack of energy

Worthlessness/guiltEating problemsPsychomotor problems

Cognitive problems

1.00

-IV Core symptoms: depressed mood/diminished interest

follow-up period (n=267)

Sleeping problems Death ideations0.80

0.60

n of

Tim

e D

SM

-st

er Is

Pre

sent

0.40

0.20

Mea

n P

ropo

rtion

Sym

ptom

Clu

0 00M 0.00

Weeks of Follow-up

DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th edition Conradi HJ, et al. Psychol Med. 2011;41:1165-1174.

Cognitive dysfunction of depression impacts onCognitive dysfunction of depression impacts onfunctionalityfunctionality11--33functionalityfunctionalityIn MDD, cognitive impairments in information processing, memory, and

verbal fluency may impact upon educational, occupational, and daily e ba ue cy ay pact upo educat o a , occupat o a , a d da yfunctioning1

Workplace functionalityWorkplace functionality• Government-commissioned research in 2010 found that

people unable to work because of depression lose £8.97 billi f t ti l i i E l d2billion of potential earnings per year in England2

• In the United States, the costs related to both absenteeism from work and presenteeism due to

$ 1 3

1. Hammar A, Ardal G. Front Hum Neurosci. 2009;3:26; 2. All-Party Parliamentary Group on Wellbeing Economics:

Cost of depression in England, 2010. Available at:

untreated depression are over $51 billion per year3

Cost of depression in England, 2010. Available at: http://wellbeingeconomics.files.wordpress.com/2012/02/costo

fdepressionstats2010.pdf. Accessed September 2014; 3. Greenberg PE, et al. J Clin Psychiatry. 2003;64(12):1465-1475. MDD, major depressive disorder.

Cognitive Cognitive SSymptoms in Depression Are ymptoms in Depression Are HHighly ighly PPrevalent and Persistent, Even revalent and Persistent, Even AAfter fter TTreatmentreatmentPPrevalent and Persistent, Even revalent and Persistent, Even AAfter fter TTreatmentreatment

44%94%

44%

%REMISSIONACUTE REMISSION

Even in patients thought to be in remission, cognitive symptoms were shown to be present in depressed patients for an average of 44% of

th ti d i i d f i i

CUIn one study, cognitive problems

dominated the course of depression and were present for up to 94% of the time during depressive episodes

Conradi HJ et al. Psychol Med. 2011;41:1165–1174.

the time during periods of remission

Evaluating Evaluating Cognitive PerformanceCognitive PerformanceDi it S b l S b tit ti T t (Di it S b l S b tit ti T t (DSST)DSST)Digit Symbol Substitution Test (Digit Symbol Substitution Test (DSST)DSST)

DSST3DSST

• Measure of processing speed, working memory and attentionworking memory and attention

• The number of correct symbols substituted for digits during atest period is measured

• Timed- Processing Speed• Involves the substitution of

simple symbols for digits-Working Memory

1. Rey. L’Examen Clinique en Psychologie. 1964. 2. Lezak. Neuropsychological Assessment. 1983.

3. Wechsler. Wechsler Adult Intelligence Scale. 1997.

Digit Symbol Substitution Test (DSST)Digit Symbol Substitution Test (DSST)Digit Symbol Substitution Test (DSST)Digit Symbol Substitution Test (DSST)

1. Wechsler. Wechsler Adult Intelligence Scale. 1997.

Remission Status of MDD Patients Has Remission Status of MDD Patients Has Significant Effects on Family MembersSignificant Effects on Family MembersSignificant Effects on Family MembersSignificant Effects on Family Members

60

Decrease in Problem Behaviors and Symptoms for Children of Depressed Mothers, by Maternal Remission Status (N=80)a

54

56

58

60p , y ( )

Early-remitting mothers Late-remitting mothers Nonremitting mothers

48

50

52

54

42

44

46

48

• Children of early- and late-remitting mothers significantly improved compared with those of nonremitting mothers (early vs nonremitting: P=0.005; late vs nonremitting: P=0.002)b

40Baseline 3 months 6 months 9 months

aaOnlyOnly data for the 9 months following remission is shown, due to high dropout rate among nondata for the 9 months following remission is shown, due to high dropout rate among non--remitters prior to month 12.remitters prior to month 12.bbChildChild Behavior Checklist was used; higher scores = greater number or severity of symptoms. Behavior Checklist was used; higher scores = greater number or severity of symptoms. 1. 1. WickramaratneWickramaratne P, et al. P, et al. Am J PsychiatryAm J Psychiatry. 2011;168:593. 2011;168:593--602. 602.

g ( y g ; g )