Functional recovery in depression: Are we doing the right thing for the treatment of depression?

Major depressive disorder (MDD) is a heterogeneous disease characterized by many different mood, physical and cognitive symptoms. The cognitive symptoms, in particular, impair psychosocial and workplace functioning. To achieve both a symptomatic and functional recovery, experts from Australia, Belgium, China and the USA advocated shared decision-making and individualized goal setting to a large symposium audience at ECNP 2018. Shared decision-making enables individualization of treatment goals and symptoms to address functional impairments specific for each patient. The outcomes that are important to the patient then need to be measured using a new scale adapted and used for the first time in depression, which incorporates all symptom domains and functional performance.

Cognitive recovery is important for functional recovery

Functional recovery from MDD facilitates psychosocial and workplace functioning, a speaker explained. Treatment strategies therefore need to address cognitive symptoms to improve symptoms associated with functioning in daily life.

They highlighted a study showing that 52% of 164 patients with MDD reported that cognitive difficulty severely interfered with their occupational functioning.2 Cognitive deficits in executive function, memory and attention persist even when depression is treated,3 she added.

Nearly 70% of patients with MDD have severe functional impairment

They also presented a study of 1,051 full-time employed people with MDD, which demonstrated a significant association between increasing severity of depression symptoms and worsening of perceived cognitive functioning based on Perceived Deficits Questionnaire (PDQ) scores (p<0.0001).5

In addition, it has been shown that workplace performance variability is explained by subjective measures of cognitive dysfunction more than total MDD symptom severity, she said.6

 

Functional impairment remains despite treatment

At diagnosis, nearly 60% of patients with MDD have severe or very severe functional impairment,4 said another presenter; and after treatment many patients continue to experience functional impairment at work7 and in their social life.8 Improving functional outcomes is therefore a treatment priority.

Many patients continue to experience functional impairment despite treatment

The negative impact of acute MDD on psychosocial functional outcome is mediated by executive and spatial cognitive functions,9 the speaker added. In the Adelaide Cognitive Function and Mood Study, executive functions were the strongest independent predictors of psychosocial outcomes in remitted patients.10

 

Physicians often overlook the importance of cognitive symptoms

The expectations of HCPs often do not match patients’ expectations of treatment for depression. The speaker described an online survey of 650 psychiatrists, 366 primary care practitioners, 30 neurologists, and 2,008 patients with MDD from Brazil, Canada, Mexico, South Korea, USA, France, Italy and Spain.

Physicians and patients do not have the same expectations from treatment

The survey revealed that when compared with responses from patients, physicians gave a lower rating to the importance of treating physical and cognitive symptoms, and the largest difference was for cognitive symptoms during the acute phase of MDD.11

 

Are we asking patients with depression the right questions?

Most psychiatrists do not measure outcome when treating patients with depression, said a speaker. When we do measure outcome, are we measuring what is important to patients? For example, in a study described by the previous speaker, 55% of 274 patients who scored ≤7 on the Hamilton Depression Rating Scale (HAM-D17) — which has not been designed to measure cognitive symptoms — did not consider that they were in remission.12

Which scales should we use? And should they be subjective or objective?

The speaker discussed the need to measure outcomes using scales that evaluate cognitive function, including:

  • The Perceived Deficits Questionnaire 20 items or 5 items (PDQ-20 or PDQ-5), which is a subjective questionnaire completed by the patient
  • The Digit Symbol Substitution Test (DSST)
  • THINC-it

Both the DSST and THINC-it provide an objective assessment of all four domains of cognitive function — executive function, psychomotor speed, attention and memory.13

If we don’t ask the right questions, what can we do better, and how can we achieve a functional recovery?

Recovery from MDD should include both symptomatic and functional recovery and involve shared decision-making, said the speaker. The goals of treatment depend on:

  • The phase of illness — all three symptom domains (mood, physical and cognitive) across all phases (acute, post-acute and remission) need to be addressed
  • The individual patient’s needs

Another speaker agreed and advocated for a shared decision-making approach that:

  • Recognises the heterogeneity of MDD and patients with MDD
  • Enables individualisation of treatment goals by involving patients in decisions

Shared decision-making, goal setting, and measuring outcomes can facilitate functional recovery

They described a goal attainment approach and explained the successful adaptation of this approach for depression, for tracking progress as patients work to attain specific goals identified as part of a treatment plan. The goals for different domains of MDD — psychological, motivational, emotional, physical and cognitive — are generated through a collaborative discussion of the patient’s experience of MDD and related symptoms, and the impact of these experiences on their life.

It is then important to measure the outcomes that are important to patients using appropriate scales that incorporate all symptom domains and functional performance.

This website has been developed by Lundbeck UK. Highlights from the symposia are a fair representation of the scientific content presented at the meeting and have been adapted for the use of UK healthcare professionals.
References
  1. Lieblich SM, et al. BJPsych Open. 2015;1,e5-e7. doi 10.1192/bjpo.bp.115.000786.
  2. Lam RW, et al. Depress Res Treat. 2012;2012:630206.
  3. Rock PL, et al. Psychol Med. 2014;44:2029–40.
  4. Fried EI, Nesse RM. PLoS One. 2014;9:e90311.
  5. Lawrence C, et al. Prim Care Companion CNS Disord. 2013;15:PCC.12m01469.
  6. McIntyre RS, et al. Compr Psychiatry. 2015;56:279–82.
  7. Lerner D, et al. J Occup Environ Med. 2008;50:401–10.
  8. Jaeger J, et al. Psychiatry Res. 2006;145:39–48.
  9. Knight MJ, et al. J Clin Psychiatry. 2019;80(1):18m12472.
  10. Knight MJ, et al. J Affect Disord. 2018;235:129-34.
  11. Baune BT. Poster presented at ECNP 2018. Poster P018.
  12. Zimmerman M, et al. J Clin Psychiatry. 2012;73(6):790–5.
  13. Ragguett R-M, et al. Evid Based Mental Health. 2016;19(4):106-9.
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