Hanipsych, functional recovery in depression


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  • 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
    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.
    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.
    Sanderson & al. Which presenteeism measures are more sensitive to depression and anxiety. J affective disorder 2006 Dec 5
  • *P<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.
    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.
    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”
    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.
    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.
    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.
  • Hanipsych, functional recovery in depression

    1. 1. 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
    2. 2. Disclosure • Some promotional data provided by Lundbeck Egypt.
    3. 3. Digestive disorder (6%) Musculoskeletal disorders (4%) Endocrine (4%) Neuropsychiatric disorders (28%) Cancer (11%) Cardiovascular disease (22%) Sense organ impairment (10%) Other non-communicable diseases (7%) Respiratory disease (8%) Schizophrenia Bipolar disorder Dementia Substance-use and alcohol-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
    4. 4. •‫يصيب‬ ‫أصبح‬ ‫الذي‬ ‫والعصبي‬ ‫النفسي‬ ‫المرض‬450.‫الرض‬ ‫سطح‬ ‫فوق‬ ‫إنسان‬ ‫مليون‬ •‫الي‬ ‫وصل‬ ‫وحده‬ ‫الكتئاب‬ ‫وان‬140,‫انسان‬ ‫مليون‬ •‫الي‬ ‫العالم‬ ‫في‬ ‫وصلت‬ ‫فقد‬ ‫والخوف‬ ‫القلق‬ ‫حالت‬ ‫أما‬200‫خائف‬ ‫انسان‬ ‫مليون‬ ..‫وقلق‬ •‫الي‬ ‫أيضا‬ ‫العالم‬ ‫في‬ ‫الدمان‬ ‫ووصل‬130..‫مدمن‬ ‫إنسان‬ ‫مليون‬ •‫و‬ ‫مليون‬ ‫وجود‬ ‫تؤكد‬ ‫فإنها‬ ‫مصر‬ ‫في‬ ‫الرقام‬ ‫أما‬200‫عذاب‬ ‫يعاني‬ ‫مصري‬ ‫إنسان‬ ‫ألف‬ .‫الكتئاب‬ ‫الرهرام‬20-10-2011
    5. 5. Face the Facts Depression is a Prevalent Disorder
    6. 6. 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)
    7. 7. Ten leading causes of burden of disease, world, 2004 and 2030
    8. 8. 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
    9. 9. Depression 20% of those with major depression have symptoms that persist beyond 2 years Keller et al., (1992) & Scot & Dicky (2003), B. J. Psychiat.
    10. 10. 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
    11. 11. Depression is an Under-recognized Disorder  Stigma  Masked depression  Comorbid medical illness  Time constraints  Inadequate medical education
    12. 12. “ICEBERG” PHENOMENON” Depressed patients seen by psychiatrists Depressed patients seen in primary care practice
    13. 13. Cost of Depression Who pays for it? • Patients • Families • Health Care Provider • System
    14. 14. 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
    15. 15. Cost of Depression Families • Increased burden • Patient being aloof from family causing more guilt and anxiety • Impaired relationship • Increased risk of violence and neglect
    16. 16. 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
    17. 17. System • Increased use of resources • Increased mortality and morbidity
    18. 18. Unmet Medical needs GPs delayed diagnosis Cross diagnosis of Bipolar Stigma Selecting the right treatment option From IV to 5
    19. 19. COST Direct • Recurrence • Treatment • Hospitalization Indirect • Disability in work • Poor social function • Associated behavioral problems • Increase self destructive behaviors
    20. 20. 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.
    21. 21. ‘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
    22. 22. 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
    23. 23. 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
    24. 24. Is real-life functionality the new goal of treatment?
    25. 25. Relapse is very Common Euthymia Symptoms Syndrome Remission Response Recovery – 6 months Continuation treatment Maintenance treatment Relapse Recurrence
    26. 26. 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
    27. 27. 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
    28. 28. 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
    29. 29. 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.
    30. 30. 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
    31. 31. 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
    32. 32. 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
    33. 33. 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–
    34. 34. 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
    35. 35. 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
    36. 36. 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
    37. 37. Influence of antidepressants on functional outcomes
    38. 38. 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
    39. 39. 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
    40. 40. 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.