From response and remission to full functional recovery in major depressive disorder: Is patient-involvement the missing link?

Depression is a common and serious illness with heterogeneous symptoms within emotional, physical and cognitive domains. Although a wide range of approved drugs for treating major depression are available, a considerable proportion of patients who meet formal criteria for remission do not consider themselves in remission, or do not obtain functional recovery. In this symposium, three experts gave their view on limitations in our current approach to treatment selection and treatment goals, and offered future directions for optimizing the treatment of depression.

Looking beyond the ‘average’ patient: A neuroscientific approach to targeting individual patient profiles

Stephen Stahl, Professor at the University of California San Diego, USA, opened the symposium explaining that clinical guidelines for the treatment of depression are based on meta-analyses typically concluding that different antidepressants are equally efficacious.1 Meta-analyses, however, Prof Stahl noted, reflect what works for the ‘average’ patient; yet many patients’ symptom profiles do not represent the ‘average’ patient. Highlighting the heterogeneity of symptoms in depression, spanning from loss of interest and fatigue to concentration problems and impaired psychomotor function, he pointed out that different pharmacological agents with different specific targets may impact on different clinical measures across the range of symptom domains. Therefore, Prof Stahl noted, we should consider the specific mechanisms of an agent relative to the symptom profile to be able to select the right treatment for the individual patient as early as possible. 

Meta-analyses reflect what works for the ‘average’ patient but many patients’ symptom profiles do not represent the ‘average’ patient.

Highlighting persistent cognitive impairment as a common and debilitating symptom in depression,2 Prof Stahl explained that while monoaminergic agents target mainly brain circuits regulating mood symptoms, multiple neurotransmitter systems are involved in cognition, including cholinergic, dopaminergic, norepinephrinergic, histaminergic, GABAergic, and glutamatergic pathways.3,4 Therefore, Prof Stahl noted, we should consider the specific mechanisms of an agent relative to the symptom profile to be able to select the right treatment for the individual patient as early as possible.

 

Closing the gap between patient and clinician perceptions to improve treatment outcomes

The next speaker, Bernhard Baune, Professor at the University of Münster, Germany, pointed out the apparent paradoxes that more than half of patients who meet criteria for remission as defined by depression scale scores, do not consider themselves in remission,2 and that many patients in symptomatic recovery continue experiencing functional impairment.3 According to Prof Baune, targeting mood symptoms is therefore necessary but not sufficient for recovery, as patients themselves consider essential a broader range of factors, including daily functioning, ability to work, and quality of life.2

Targeting mood symptoms is necessary but not sufficient for recovery, as patients consider essential a broader range of symptoms and factors, including daily functioning, ability to work, and quality of life.

Prof Baune supported his point presenting recently published data from a survey study,4 showing that patients in remission reported worse symptoms levels across mood, cognitive, and physical domains, and felt more functionally impaired than perceived by clinicians. Clinicians also tended to focus on alleviating mood symptoms in the acute phase whereas patients experienced a need for improving both mood and functioning across all phases.

Pointing out the need for closing this gap between patients’ and clinicians’ perceptions of symptoms and treatment goals to improve treatment outcomes, Prof Baune emphasized the importance of shared decision making, with the remission phase as a particularly critical time window for ensuring continuous improvement and restoring full functional recovery.

 

Novel approaches to measuring treatment progression may help promote functional recovery

Roger McIntyre, Professor at the University of Toronto, Canada, elaborated on the importance of involving patients in the identification of treatment goals, pointing out the value of patient-reported outcomes when assessing therapeutic objectives and progress, as they may tap into areas that remain unmet needs in the treatment of depression, such as quality of life and functional improvement, including work functioning.

Prof McIntyre highlighted goal attainment scaling (GAS)5 as a unique, patient-centered approach to assessing treatment progress and treatment success. With GAS, treatment goals are agreed upon based on a dialogue between clinician and patient and include not only improvement of mood symptoms, but also functional goals related to daily activities and well-being, thus broadening the focus of treatment from symptomatic remission to functional recovery.6

Patient-reported outcomes are valuable when assessing therapeutic objectives and progress, as they typically tap into areas that remain unmet needs in the treatment of depression.

Prof McIntyre concluded the symposium by urging the consideration of all the different components of depression as treatment goals, including cognitive symptoms that have been shown to be particularly important for work functioning,7 to be able to restore daily functioning, enhance quality of life and help patients return to meaningful and productive lives.

 

Educational financial support for this 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. Cipriani A et al. Lancet 2018; 391: 1357–1366.

2. Zimmerman M, et al. J Clin Psychiatry. 2012;73(6):790–95

3. Papakostas GI. Am J Manag Care 2009; 15: S316-S321

4. Baune BT, Christensen MC. Front Psychiatry 2019; 10: 335.

5. Kiresuk TJ, Sherman RE. Community Ment Health J 1968; 4: 443–453.

6. McCue M et al. Poster 232 presented at the Psych Congress 2018.

7. Chokka P et al. CNS Spectr 2019; 24: 338–347. 28–31 May, 2019.

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