Improving Improving Outcomes in Major Depression: Outcomes in Major - PowerPoint PPT Presentation

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

Top 3: Sleep, mood and concentration Top 3: Sleep, mood and concentration Prevalence of Symptoms During MDD Episodes Prevalence of Symptoms During MDD Episodes Prevalence of Symptoms During MDD Episodes Prevalence of Symptoms During MDD Episodes 0% 20% 40% 60% 80% 100% Depressed mood Sleep problems Sleep problems • 13-year NIMH Study of Trouble thinking 1,920 Individuals in the Appetite problems Thoughts of death Thoughts of death Baltimore Epidemiologic Baltimore Epidemiologic Lost interest Catchment Area Tiredness Worthlessness Worthlessness Slowness/restlessness 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 Remission Most Patients Fail to Achieve Remission Most Patients Fail to Achieve Remission Most Patients Fail to Achieve Remission Sequenced 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 settings settings 80% of patients had chronic or recurrent depression 80% of patients had chronic or recurrent depression –  First  First First-line treatment First-line treatment line treatment line 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) Response Remission rate rate 28% 47% 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 Trivedi MH, et al. T i Trivedi MH, et al. Am J Psychiatry. di MH di MH t t l l A Am J Psychiatry. 2006;163:28 2006;163:28-40. 2006 163 28 40 2006 163 28 40. 40 A J P J P hi t hi t inhibitor. inhibitor.

Depressive symptoms persist during periods of remission and Depressive symptoms persist during periods of remission and subsequent depressive episodes subsequent depressive episodes subsequent depressive episodes subsequent depressive episodes Mean proportion of time DSM-IV symptoms are present during 3-year follow-up period (n=267) follow-up period (n=267) Worthlessness/guilt Cognitive problems Core symptoms: depressed mood/diminished interest Eating problems 1.00 -IV Lack of energy Psychomotor problems n of Time DSM- ster Is Present Sleeping problems Death ideations 0.80 0.60 Mean Proportion Symptom Clu 0.40 0.20 0 00 0.00 M Weeks of Follow-up DSM-IV, Diagnostic and Statistical Manual of Conradi HJ, et al. Psychol Med. 2011;41:1165-1174 . Mental Disorders, 4 th edition

Cognitive dysfunction of depression impacts on Cognitive dysfunction of depression impacts on functionality 1- -3 3 functionality functionality functionality In 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 y functioning 1 Workplace functionality Workplace functionality • Government-commissioned research in 2010 found that people unable to work because of depression lose £8.97 billion of potential earnings per year in England 2 d 2 billi f t ti l i i E l • In the United States, the costs related to both absenteeism from work and presenteeism due to untreated depression are over $51 billion per year 3 3 $ 1 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: Cost of depression in England, 2010. Available at: http://wellbeingeconomics.files.wordpress.com/2012/02/costo fdepressionstats2010.pdf. Accessed September 2014; MDD, major depressive disorder. 3. Greenberg PE, et al. J Clin Psychiatry . 2003;64(12):1465-1475.

Cognitive Cognitive S Symptoms in Depression Are ymptoms in Depression Are H Highly ighly Prevalent and Persistent, Even Prevalent and Persistent, Even revalent and Persistent, Even After revalent and Persistent, Even After fter Treatment fter Treatment reatment reatment 44% 44% 94 % % REMISSION REMISSION ACUTE CU In one study, cognitive problems Even in patients thought to be in dominated the course of depression remission, cognitive symptoms were and were present for up to 94% of shown to be present in depressed patients for an average of 44% of the time during depressive episodes th the time during periods of remission ti d i i d f i i Conra Conradi i HJ e HJ et al. al. Psy Psycho hol Med l Med . 20 . 2011;4 ;41:1 1:1165–1 65–1174. 4.

Evaluating Cognitive Performance Evaluating Cognitive Performance Di it S Di it S Digit Symbol Substitution Test (DSST) Digit Symbol Substitution Test ( b l S b tit ti b l S b tit ti T T t ( t (DSST) DSST) DSST) DSST 3 DSST • Measure of processing speed, working memory and attention working memory and attention The number of correct • symbols substituted for digits during a test 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 Members Significant Effects on Family Members Significant Effects on Family Members Significant Effects on Family Members Decrease in Problem Behaviors and Symptoms for Children of Depressed Mothers, by Maternal Remission Status (N=80) a p , y ( ) 60 60 Early-remitting mothers Late-remitting mothers Nonremitting mothers 58 56 54 54 52 50 48 48 46 44 42 Baseline 3 months 6 months 9 months 40 • 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 g ( y g ; g ) a Only Only data for the 9 months following remission is shown, due to high dropout rate among non data 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. b Child Child 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. Wickramaratne Wickramaratne P, et al. P, et al. Am J Psychiatry Am J Psychiatry . 2011;168:593 . 2011;168:593- -602. 602.