Kate Johnson

October 02, 2012

October 2, 2012 (Montreal, Canada) — The treatment of major depressive disorder (MDD) should go beyond the goal of symptom relief to include a more global target of improving patients' overall and occupational functioning.

This shift is reflected in new consensus recommendations currently being finalized by the Canadian Network for Mood and Anxiety Treatments (CANMAT).

"The focus on symptoms doesn't necessarily make sense for our patients because they're primarily concerned about their functioning. And so we think we need to move the bar now — raise the bar — in terms of our assessment of outcomes. The ideal outcome really should be functional recovery," Raymond Lam, MD, executive chair of the network, told delegates attending the Canadian Psychiatric Association (CPA) 62nd Annual Conference.

Studies show that MDD has a significant impact on work functioning, yet roughly 70% of people with MDD remain at work.

"Our view is that unless there are safety issues, it's better for patients to be trying to stay at work while they're being treated rather than being off work. The longer they're off work, the harder it is to get them back," said Dr. Lam, who is also professor of psychiatry and head of the Mood and Anxiety Disorders Program, University of British Columbia in Vancouver, Canada.

Because "the trajectory and time course of functional improvement may not mirror that of symptom improvement," treatment that addresses symptoms alone may miss an important part of the picture, he said.

Subtle Outcomes

According to a needs assessment survey done primarily with family physicians, although most physicians recognize that functioning is a major determinant in treating people with depression, "there is a knowledge gap in terms of how functioning issues present," Dr. Lam added.

To rate and monitor improvement in work functioning outcomes, the CANMAT statement recommends the use of clinician-rated scales such as the Health and Work Performance Questionnaire (HPQ) and the Lam Employment Absence and Productivity Scale (LEAPS) (BMC Psychiatry 2009;9:78-85), which was developed by Dr. Lam.

A new study by Dr. Lam's group, which is currently under review, shows how such work performance scales are able to pick up subtle outcomes that can be missed on general symptom scales such as the Montgomery-Åsberg Depression Rating Scale (MADRS).

The Worker Outcome Research and Knowledge about Escitalopram and Related Treatments (WORKER) study is the first randomized controlled trial of pharmacotherapy and psychotherapy focusing specifically on work productivity outcomes, said Dr. Lam.

Better Productivity

A total of 105 employed patients with MDD were randomly assigned to undergo treatment with either escitalopram (10 - 20 mg/day) for 12 weeks plus 8 one-half-hour sessions of telephone cognitive-behavioral therapy (CBT) or escitalopram alone with adherence reminder calls.

Symptom response and remission were measured on the MADRS, and functioning was measured on both the HPQ and the LEAPS as well as a third functioning scale, the Sheehan Disability Scale (SDS),

After 12 weeks, there was no significant difference between the groups in terms of symptom outcome, with MADRS responder rates at 56% for patients in the combination therapy group vs 53% for patients receiving escitalopram alone (MADRS scores, 15.7 vs 14.3).

However, on the outcome of work functioning, participants receiving combination therapy had greater improvements than those receiving escitalopram alone on both the HPQ (1.2 vs 0.5, P < .05) and the LEAPS (3.9 vs 2.5, P < .04).

"We think these are clinically relevant differences in work productivity," he said.

There were no differences between the groups on the SDS, "but the SDS is really a global measure and only has 1 item on overall work and role function," he explained. "Using a 1-item scale may not be sensitive enough in a relatively small sample."

The findings show that although symptoms can resolve with medication alone, there was residual functional impairment.

"People's occupational functioning obviously improved when they were on the antidepressant alone, it's just they got a bump-up in terms of productivity with the combined treatment.... This is why we feel it's so important to incorporate functional outcome measures, because we may be missing the fact that some treatments are going to be better for functioning than others."

A "Practical Goal"

After attending the presentation, conference delegate Derryck Smith, MD, clinical professor of psychiatry, University of British Columbia, who is also a psychiatrist in private practice in Vancouver, said he agreed with the recommendations.

"We're trying to get people better, not just get rid of symptoms. We have to work towards a practical goal," he told Medscape Medical News.

"We need to help make people more successful in their life in general, in their relationships, as well as how they're doing in their job...and maybe even in the physical aspects — are they back to running, for example? Are they back to their hobbies? Are they doing well socially?

"Even if their symptoms are reduced, you may have to find out why they're not back at work. Maybe it's because they're not sleeping, maybe it's because they're having cognitive difficulties," he said.

He added that the current DSM-IV diagnostic criteria include "a unique cluster of symptoms that defines an illness, but you always have to have functional impairment to make the diagnosis, and it doesn't define what functional impairment is."

He said that objective functional outcome measures are much needed for this assessment.

The study and symposium were funded by Lundbeck Canada. Dr. Lam holds the copyright on the LEAPS, but it is free for clinical use. He also disclosed the following relationships: speaker/consulting Honoraria: AstraZeneca, Biovail, Bristol Myers Squibb, CANMAT, Common Drug Review, Eli Lilly, GlaxoSmithKline, Lundbeck, LundbeckInstitute, Mochida, Pfizer, Servier, Takeda; clinical trials/grants: AquaceuticaGroup,AstraZeneca, Bristol Myers Squibb Canadian Institutes of Health Research, Canadian Psychiatric Association Foundation, CANMAT, LundbeckCanada, Litebook Company, Inc, Michael Smith Foundation for Health Research, Pfizer, St. Jude Medical, UBC Institute of Mental Health/Coast Capital Savings. Dr. Smith has disclosed no relevant financial relationships.

Canadian Psychiatric Association (CPA) 62nd Annual Conference. Abstracts Ps5b and S11. Presented September 29, 2012.