Towards personalizing treatment for depression : developing treatment values markers

Depressive symptom heterogeneity among older adults after hip fracture

OBJECTIVE

to evaluate patterns of depressive symptoms after hip fracture and examine their impact on functional recovery.

METHODS

participants (n = 304) included older adults from the Baltimore Hip Studies 7th cohort who experienced a hip fracture. Depressive symptoms were measured at baseline or 2-, 6- or 12-month post-hip fracture using the 20-item Center for Epidemiologic Studies Depression scale. Gait speed was measured after hip fracture at 2-, 6- or 12-month follow-up. Latent class analysis was used to identify individuals with similar patterns of depressive symptoms after hip fracture. Item response probabilities characterised symptom profiles, and posterior probability estimates were used to assign participants to a baseline depressive symptom subtype. Weighted estimated equations compared post-fracture gait speed between baseline symptomatic and asymptomatic groups.

RESULTS

four patterns of depressive symptoms were identified: asymptomatic (50.8%), somatic (28.6%), melancholic (11.4%) and anhedonic (9.2%). The somatic subtype was characterised by difficultly concentrating and reduced energy and movement, whereas anhedonic symptoms were associated with the inability to experience pleasure. Melancholic symptoms corresponded to anhedonia, decreased physical activity and other psychological and somatic complaints. Compared with the asymptomatic group, somatic symptoms were consistently associated with slower gait speed, -0.03 metres per second (m/s) and between-group differences for melancholic symptomology were as large as -0.05 m/s, but the associations were not statistically significant.

CONCLUSION

findings demonstrate unique depressive symptom subtypes in older adults after hip fracture and provide confirmatory evidence of unique clinical phenotypes; however, their impact on functional recovery after hip fracture remains unclear.

Patient-Centered Care for Patients with Depression or Anxiety Disorder: An Integrative Review

People have specific and unique individual and contextual characteristics, so healthcare should increasingly opt for person-centered care models. Thus, this review aimed to identify and synthesize the indicators for the care process of the person with depression and/or anxiety disorders, based on patient-centered care, going through the stages of diagnostic assessment and care planning, including intervention. An integrative literature review with research in seven scientific databases and a narrative analysis were carried out. Twenty articles were included, with indicators for diagnostic evaluation and care/intervention planning being extracted. Care planning focused on people with depression and/or anxiety disorder must be individualized, dynamic, flexible, andparticipatory. It must respond to the specific needs of the person, contemplating the identification of problems, the establishment of individual objectives, shared decision making, information and education, systematic feedback, and case management, and it should meet the patient’s preferences and satisfaction with care and involve the family and therapeutic management in care. The existence of comorbidities reinforces the importance of flexible and individualized care planning in order to respond to the specific health conditions of each person.

Personalising psychotherapies for depression using a novel mixed methods approach: an example from Morita therapy

Background

Current quantitative methods for personalising psychotherapies for depression are unlikely to be able to inform clinical decision-making for hundreds of years. Novel alternative methods to generate hypotheses for prospective testing are therefore required, and we showcase mixed methods as one such approach. By exploring patients’ perspectives in depth, and integrating qualitative and quantitative data at the level of the individual, we may identify new potential psychosocial predictors of psychotherapy outcomes, potentially informing the personalisation of depression treatment in a shorter timeframe. Using Morita therapy (a Japanese psychotherapy) as an exemplar, we thus explored how Morita therapy recipients’ views on treatment acceptability explain their adherence and response to treatment.

Methods

The Morita trial incorporated a pilot randomised controlled trial of Morita therapy versus treatment as usual for depression, and post-treatment qualitative interviews. We recruited trial participants from general practice record searches in Devon, UK, and purposively sampled data from 16 participants for our mixed methods analysis. We developed typologies of participants’ views from our qualitative themes, and integrated these with quantitative data on number of sessions attended and whether participants responded to treatment in a joint typologies and statistics display. We enriched our analysis using participant vignettes to demonstrate each typology.

Results

We demonstrated that (1) participants who could identify with the principles of Morita therapy typically responded to treatment, regardless of how many sessions they attended, whilst those whose orientation towards treatment was incompatible with Morita therapy did not respond to treatment, again regardless of treatment adherence and (2) participants whose personal circumstances impeded their opportunity to engage in Morita therapy attended the fewest sessions, though still benefitted from treatment if the principles resonated with them.

Conclusions

We identified new potential relationships between “orientation” and outcomes, and “opportunity” and adherence, which could not have been identified using existing non-integrative methods. This mixed methods approach warrants replication in future trials and with other psychotherapies to generate hypotheses, based on typologies (or profiles) of patients for whom a treatment is more or less likely to be suitable, to be tested in prospective trials.

Trial registration

Current Controlled Trials, ISRCTN17544090. Registered on 23 July 2015.

Patient preferences for important attributes of bipolar depression treatments: a discrete choice experiment

PURPOSE

The purpose of this study was to assess patient preferences regarding pharmacological treatment attributes for bipolar depression using a discrete choice experiment (DCE).

METHODS

Adult members of an Internet survey panel with a self-reported diagnosis of bipolar depression were invited via e-mail to participate in a web-based DCE survey. Participants were asked to choose between hypothetical medication alternatives defined by attributes and levels that were varied systematically. The six treatment attributes included in the DCE were time to improvement, risk of becoming manic, weight gain, risk of sedation, increased blood sugar, and increased cholesterol. Attributes were supported by literature review, expert input, and results of focus groups with patients. Sawtooth CBC System for Choice-Based Conjoint Analysis was used to estimate the part-worth utilities for the DCE analyses.

RESULTS

The analytical sample included 185 participants (50.8% females) from a total of 200 participants. The DCE analyses found weight gain to be the most important treatment attribute (relative importance =49.6%), followed by risk of sedation (20.2%), risk of mania (13.0%), increased blood sugar (8.3%), increased cholesterol (5.2%), and time to improvement (3.7%).

CONCLUSION

Results from this DCE suggest that adults with bipolar depression considered risks of weight gain and sedation associated with pharmacotherapy as the most important attributes for the treatment of bipolar depression. Incorporating patient preferences in the treatment decision-making process may potentially have an impact on treatment adherence and satisfaction and, ultimately, patient outcomes.

Methods for Incorporating Patient Preferences for Treatments of Depression in Community Mental Health Settings

We developed three methods (rating, ranking, and discrete choice) for identifying patients' preferred depression treatments based on their prioritization of specific treatment attributes (e.g., medication side effects, psychotherapy characteristics) at treatment intake. Community mental health patients with depressive symptoms participated in separate studies of predictive validity (N = 193) and short-term (1-week) stability (N = 40). Patients who received non-preferred initial treatments (based on the choice method) switched treatments significantly more often than those who received preferred initial treatments. Receiving a non-preferred treatment at any point (based on rating and choice methods) was a significant predictor of longer treatment duration. All three methods demonstrated good short-term stability.

A Comparison of Methods for Capturing Patient Preferences for Delivery of Mental Health Services to Low-Income Hispanics Engaged in Primary Care

BACKGROUND

Consideration of patient preferences regarding delivery of mental health services within primary care may greatly improve access and quality of care for the many who could benefit from those services.

OBJECTIVES

This project evaluated the feasibility and usefulness of adding a consumer-products design method to qualitative methods implemented within a community-based participatory research (CBPR) framework.

RESEARCH DESIGN

Discrete-choice conjoint experiment (DCE) added to systematic focus group data collection and analysis.

SUBJECTS

Focus group data were collected from 64 patients of a Federally-Qualified Health Center (FQHC) serving a predominantly low-income Hispanic population. A total of 604 patients in the waiting rooms of the FQHC responded to the DCE.

MEASURES

The DCE contained 15 choice tasks that each asked respondents to choose between three mental health services options described by the levels of two (of eight) attributes based on themes that emerged from focus group data.

RESULTS

The addition of the DCE was found to be feasible and useful in providing distinct information on relative patient preferences compared with the focus group analyses alone. According to market simulations, the package of mental health services guided by the results of the DCE was preferred by patients.

CONCLUSIONS

Unique patterns of patient preferences were uncovered by the DCE and these findings were useful in identifying pragmatic solutions to better address the mental health service needs of this population. However, for this resource-intensive method to be adopted more broadly, the scale of the primary care setting and/or scope of the issue addressed have to be relatively large.

Participant Preferences for Pharmacologic Chronic Pain Treatment Trial Characteristics: An ACTTION Adaptive Choice-Based Conjoint Study

Barriers to clinical trial recruitment can delay study completion, potentially resulting in increased costs and an unrepresentative sample. In the current study of 150 participants with chronic pain, we used a computerized adaptive choice-based conjoint survey that included 8 characteristics that may affect enrollment in pharmacologic pain treatment trials (ie, treatment allocation, frequency of pain ratings, treatment administration method, current medications, number of study visits, availability of evening and weekend visits, invasiveness of laboratory procedures, payment). These data were analyzed using Sawtooth Software ver. 8.4.8 (Sawtooth Software, Inc, Orem, UT), which identifies the characteristics that dominate participants' decisions across multiple sets of potential trials. Three characteristics had the largest relative importance in participants' trial preferences: 1) invasiveness of required laboratory procedures (ie, 22%), with no procedures or blood tests preferred over ice-water sensory testing or skin biopsy; 2) ability to continue current pain medications (21%); and 3) payment for study participation (21%), with higher payment preferred. The fourth most important characteristic was number of study visits (13%), with participants preferring fewer in-person visits and more phone contacts. Understanding the preferences of potential participants is an important step toward enhancing enrollment in pain treatment trials.

PERSPECTIVE

This article presents the preferences of individuals with chronic pain conditions regarding modifiable pain treatment trial characteristics (eg, number of study visits, payment, treatment allocation). These findings may help to improve enrollment into analgesic clinical trials and in turn accelerate the development of new pain treatments.

Why don't patients take their analgesics? A meta-ethnography assessing the perceptions of medication adherence in patients with osteoarthritis

Whilst analgesics and medications have demonstrated efficacy for people with osteoarthritis, their effectiveness is dependent on adherence. This has previously been reported as particularly low in this population. The purpose of this meta-ethnography was to explore possible perceptions for this. A systematic review of published and unpublished literature was undertaken. All qualitative studies assessing the attitudes or perceptions of people with osteoarthritis towards medication adherence were eligible. Study quality was assessed using the Critical Appraisal Skills Programme qualitative tool. Analysis was undertaken using a meta-ethnography approach, distilling to a third-order construct and developing a line of argument. From 881 citations, five studies met the eligibility criteria. The meta-ethnography generated a model where medication adherence for people with osteoarthritis is perceived as a balance between the willingness and preference to take medications with the alterative being toleration of symptoms. Motivators to influence this 'balance' may fluctuate and change over time but include: severity of symptoms, education and understanding of osteoarthritis and current medications, or general health which may raise issues for poly-pharmacy as other medications are added or substituted into the patient's formulary. Medicine adherence in people with osteoarthritis is complex, involving motivators which will fluctuate in impact on individuals at different points along the disease progression. Awareness of each motivator may better inform clinicians as to what education, support or change in prescription practice should be adopted to ensure that medicine adherence is individualised to better promote long-term behaviour change.

Nutzung von Conjoint-Analysen zur Messung von Therapiezielpräferenzen aus Patientenperspektive in der Behandlung psychischer Störungen

Hintergrund: Im Zuge der wachsenden Bedeutung von Ansätzen zur Patientenorientierung und -partizipation in der Gesundheitsversorgung gewinnt die Bestimmung subjektiver Therapiezielpräferenzen unterschiedlicher Akteure (Patienten, Behandler, Angehörige) zunehmend an Forschungsinteresse. Stated-Preference-Methods ermöglichen die systematische Untersuchung speziell patientenorientierter Fragestellungen. Ziele der Studie: Identifikation und Beschreibung (nach formalen, methodischen und inhaltlichen Merkmalen) von Studien mit Stated-Preference-Methods (Conjoint Measurements, Conjoint Analysis, Discrete Choice Experiments) in der Versorgung von Patienten mit psychischen Störungen mit dem Ziel, eine Bewertung zur Anwendbarkeit der Methode (Potential, Nutzen, Grenzen) in zukünftiger patientenorienterter Forschung abzuleiten. Methode: Systematische Literaturrecherche mit folgenden Studieneinschlusskriterien: Participants: Interventionen zur Behandlung von Patienten mit psychischer Störung; Intervention: psychotherapeutische, psychiatrische, hausärztliche Behandlungen (stationär, teil-stationär, ambulant); Comparison: Studien mit keiner (Ein-Gruppen-Design) oder mindestens einer Kontrollgruppe; Outcomes: conjoint-spezifische Angaben zu Nutzenwerten. Ergebnisse: Conjoint-Analysen werden in unterschiedlichen Forschungsdesigns und unter heterogenen Rahmenbedingungen (Stichprobe, Störungsbild, Setting, Intervention, Zieldimension) zur Messung von Therapiezielpräferenzen eingesetzt. Die Erstellung des Conjoint-Designs erfolgt in der Regel reduziert (orthogonal), mithilfe von Softwarepaketen, die Erhebung als Fragebogen. Schlussfolgerungen: Conjoint-Analysen ermöglichen differenzierte Aussagen über Therapiepräferenzstrukturen auf Basis relationaler Beurteilungsszenarien und stellen damit eine fundiertere Basis zur Verbesserung der Patientenorientierung in der Gesundheitsversorgung zur Verfügung. Die Befundlage belegt, dass sich die Methode zur Untersuchung patientenorientierter Fragestellungen (mehrheitlich zu Pharmakotherapie und Kombinationsbehandlung) in der Versorgung psychischer Störungen (depressive Störungen, ADHS, Schizophrenie, bipolare Störungen, Tabak- und Alkoholabhängigkeit und chronische Schmerzen) eignet. Allerdings ist der erfolgreiche Einsatz der Methodik an einige Voraussetzungen geknüpft (u. a. Unabhängigkeit der betrachteten Therapiezielaspekte, Designkomplexität). Forschungsbedarf besteht u. a. im Hinblick auf bisher nicht untersuchte Störungsbilder (u. a. somatoforme, Angst-, Ess-, Persönlichkeitsstörungen) und Interventionen (u. a. reine Psychotherapie, störungsspezifische Behandlungen).

Understanding preferences for disease-modifying drugs in osteoarthritis

OBJECTIVE

Numerous disease-modifying drugs for osteoarthritis (DMOADs) are under investigation. However, patients' preferences for drugs to prevent progression of OA are not known. The objective of this study was to quantify patient preferences for potential DMOADs.

METHODS

We administered a conjoint analysis survey to 304 patients attending outpatient general medicine and specialty clinics. All patients seated in the waiting rooms were asked if they would participate in a survey to elicit opinions about arthritis treatments. We performed simulations to estimate preferences for 4 options to prevent worsening of knee OA: best case (pill, highest benefit, lowest risk, lowest cost), worst case (infusion, lowest benefit, highest risk, highest cost), moderate subcutaneous injection (injection, mid-level benefit, mid-level risk, mid-level cost), and moderate infusion (same as subcutaneous injection except administered by infusion).

RESULTS

Subjects' median age was 57 years; 55% were women and 76% were white. Segmentation analyses revealed 4 patterns of preferences. A minority (5%) did not want to perform subcutaneous injections and would only consider DMOADs under the best-case scenario. Approximately 20% were risk sensitive and were willing to take DMOADs under the best-case scenario, but would start rejecting these medications as risk increased. A significant number rejected DMOADs under all conditions (16.4%); however, the largest segment (59.2%) had a strong preference for DMOADs across all scenarios.

CONCLUSION

Our results suggest that a significant percentage of a nonselected outpatient population might be willing to accept at least a moderate degree of risk in order to prevent worsening knee OA.