The influence of specific chronic somatic conditions on the care for co-morbid depression in general practice

The cost-utility of stepped-care algorithms according to depression guideline recommendations - Results of a state-transition model analysis

BACKGROUND

Evidence-based clinical guidelines for major depressive disorder (MDD) recommend stepped-care strategies for sequencing evidence-based treatments conditional on treatment outcomes. This study aims to evaluate the cost-effectiveness of stepped care as recommended by the multidisciplinary clinical guideline vis-à-vis usual care in the Netherlands.

METHODS

Guideline-congruent care as described in stepped-care algorithms for either mild MDD or moderate and severe MDD was compared with usual care in a health-economic state-transition simulation model. Incremental costs per QALY gained were estimated over five years from a healthcare perspective.

RESULTS

For mild MDD, the cost-utility analysis showed a 67% likelihood of better health outcomes against lower costs, and 33% likelihood of better outcomes against higher costs, implying dominance of guideline-congruent stepped care. For moderate and severe MDD, the cost-utility analysis indicated a 67% likelihood of health gains at higher costs following the stepped-care approach and 33% likelihood of health gains at lower costs, with a mean ICER of about €3,200 per QALY gained. At a willingness to pay threshold of €20,000 per QALY, the stepped-care algorithms for both mild MDD and moderate or severe MDD is deemed cost-effective compared to usual care with a greater than 95% probability.

LIMITATIONS

The findings of our decision-analytic modelling are limited by the accuracy and availability of the underlying evidence. This hampers taking into account all individual differences relevant to optimise treatment to individual needs.

CONCLUSIONS

It is highly likely that guideline-congruent stepped care for MDD is cost-effective compared to usual care. Our findings support current guideline recommendations.

The challenge of comorbidity in clinical trials for multiple sclerosis

OBJECTIVE

We aimed to provide recommendations for addressing comorbidity in clinical trial design and conduct in multiple sclerosis (MS).

METHODS

We held an international workshop, informed by a systematic review of the incidence and prevalence of comorbidity in MS and an international survey about research priorities for studying comorbidity including their relation to clinical trials in MS.

RESULTS

We recommend establishing age- and sex-specific incidence estimates for comorbidities in the MS population, including those that commonly raise concern in clinical trials of immunomodulatory agents; shifting phase III clinical trials of new therapies from explanatory to more pragmatic trials; describing comorbidity status of the enrolled population in publications reporting clinical trials; evaluating treatment response, tolerability, and safety in clinical trials according to comorbidity status; and considering comorbidity status in the design of pharmacovigilance strategies.

CONCLUSION

Our recommendations will help address knowledge gaps regarding comorbidity that interfere with the ability to interpret safety in monitored trials and will enhance the generalizability of findings from clinical trials to "real world" settings where the MS population commonly has comorbid conditions.

Physical and Mental Functioning in Patients with Established Rheumatoid Arthritis over an 11-year Followup Period: The Role of Specific Comorbidities

Objective.

To investigate the longterm association of a wide range of comorbidities with physical and mental functioning in patients with rheumatoid arthritis (RA).

Methods.

Longitudinal data over a period of 11 years were collected from 882 patients with RA. Somatic comorbidity and comorbid depression were measured at baseline, with a questionnaire including 20 chronic diseases and with the Center for Epidemiologic Depression Scale, respectively. Physical functioning was measured at 5 timepoints with a disease-specific measure [Health Assessment Questionnaire (HAQ)] and a generic measure [physical scales of the Medical Outcomes Study Short Form-36 (SF-36)]. Mental functioning was measured with the mental scales of the SF-36. To determine the association of baseline-specific comorbidities with functioning over time, we performed longitudinal analyses.

Results.

At baseline, 72% percent of the patients were women, mean age ± SD was 59.3 ± 14.8 years, median RA disease duration was 5.0 years, and 68% had ≥ 1 comorbid condition. The effect of comorbid conditions was more apparent when physical functioning was measured with SF-36, a disease-generic measure, compared with the HAQ, a disease-specific measure. Circulatory conditions and depression were associated (p < 0.05) with worse physical functioning according to the HAQ. Respiratory conditions, musculoskeletal conditions, cancer, and depression were associated (p < 0.05) with worse physical functioning according to the SF-36. Respiratory conditions and depression were associated with worse mental functioning.

Conclusion.

Patients with specific comorbid conditions have an increased risk of low functioning in the long term. Targeted attention for these specific comorbid conditions by clinicians is recommended.

Prevalence and prescription of antidepressants in depression with somatic comorbidity in Asia: the Research on East Asian Psychotropic Prescription Patterns study

Background:

Depression is often comorbid with chronic somatic diseases. Few previous studies have investigated the prevalence of somatic diseases in depression or the prescription pattern of antidepressants in comorbidly depressed patients in Asia. This study aimed to investigate the prevalence of somatic comorbidity (SC) in depression and compared the prescriptions of antidepressants in depressed patients with and without SC.

Methods:

A total of 2320 patients treated with antidepressants in 8 Asian countries were examined, and a diagnosis was based on the International Classification of Disease, 10^th revision. We listed 17 common chronic somatic diseases. Patients’ socio-demographic and clinical characteristics and psychotropic drug prescriptions were recorded using a standardized protocol and data collection procedure.

Results:

Of the patients examined, 1240 were diagnosed with depression and 30% of them (n = 375) had SC. The most common comorbid condition was diabetes (23.7%). The patients with SC were more likely to seek help at a general hospital (74.7% vs. 47.2%), and had a higher incidence of symptoms involving sadness, disturbed sleep, and poor appetite. Noradrenergic and specific serotonergic antidepressant was prescribed more for patients with SC than for those without SC (30.4% vs. 22.9%).

Conclusions:

SC is common in depressed Asian patients. It is important to strengthen the recognition of depression, especially in general hospitals and when patients report some somatic discomfort. It is also a matter of urgency to establish evidence-based guidelines for the use of new antidepressants in depressed patients with SC.

Chronic physical comorbidity burden and the quality of depression treatment in primary care: a systematic review

OBJECTIVE

We examined whether the treatment and follow-up care for depression in routine primary care differs between adults with higher chronic physical comorbidity burden compared to adults with lower chronic physical comorbidity burden and explored factors leading to divergent results across studies.

METHODS

We conducted a systematic review of English and French articles using Medline, Embase, PsycINFO, CINAHL and Cochrane Controlled Trials Register from inception to July 2013. Reference list and reverse citation searches were also conducted. Search terms included depression, primary care, general practitioner, chronic disease and comorbidity. Study eligibility required inclusion of relevant quality indicators and data contrasting participants with higher and lower chronic physical comorbidity burden. Study selection and quality appraisal were carried out independently by two review authors. A narrative synthesis of results was performed.

RESULTS

Our search yielded 5817 unique citations and 46 studies met inclusion criteria. Studies provided data on quality of pharmacotherapy (n=28), psychotherapy (n=4), combined measures of treatment quality (n=14), and follow-up care (n=9). Across studies, evidence that higher chronic physical comorbidity burden was associated with lower depression treatment or follow-up care quality was reported in 13 studies whereas evidence for the opposite relationship was reported in 15 studies. Four studies reported mixed results and 14 studies observed no relationships between comorbidity burden and depression treatment or follow-up care quality.

CONCLUSION

Review findings suggest that chronic physical comorbidity does not consistently lead to lower quality of depression treatment or follow-up care in primary care.

Quality of depression treatment in Black Americans with major depression and comorbid medical illness

OBJECTIVE

The objective was to evaluate how comorbid type 2 diabetes (T2DM) and hypertension (HT) influence depression treatment and to assess whether these effects operate differently in a nationally representative community-based sample of Black Americans.

METHODS

Data came from the National Survey of American Life (N=3673), and analysis is limited to respondents who met lifetime criteria for major depression (MD) (N=402). Depression care was defined according to American Psychiatric Association (APA) guidelines and included psychotherapy, pharmacotherapy and satisfaction with services. Logistic regression was used to examine the effects of T2DM and HT on quality of depression care.

RESULTS

Only 19.2% of Black Americans with MD alone, 7.8% with comorbid T2DM and 22.3% with comorbid HT reported APA-guideline-concordant psychotherapy or antidepressant treatment. Compared to respondents with MD alone, respondents with MD+T2DM/HT were no more or less likely to receive depression care. Respondents with MD+HT+T2DM were more likely to report any guideline-concordant care (odds ratio=3.32; 95% confidence interval, 1.07-10.31).

CONCLUSIONS

Although individuals with MD and comorbid T2DM+HT were more likely to receive depression care, guideline-concordant depression care is low among Black Americans, including those with comorbid medical conditions.

Primary care practice characteristics associated with the quality of care received by patients with depression and comorbid chronic conditions

OBJECTIVE

This study aimed to identify primary care practice characteristics associated with the quality of depression care in patients with comorbid chronic medical and/or psychiatric conditions.

METHOD

Using data from cross-sectional organizational and patient surveys conducted within 61 primary care clinics in Quebec, Canada, the relationships between primary care practice characteristics, comorbidity profile, and the recognition and minimally adequate treatment of depression were assessed using multilevel logistic regression analysis with 824 adults with past-year depression and comorbid chronic conditions.

RESULTS

Likelihood of depression recognition was higher in clinics where accessibility of mental health professionals was not viewed to be a major barrier to depression care [odds ratio (OR)=1.61; 95% confidence interval (CI) 1.13-2.30]. Four practice characteristics were associated with minimal treatment adequacy: greater use of treatment algorithms for depression (OR=1.77; 95% CI=1.18-2.65), high value given to teamwork (OR=2.48; 95% CI=1.40-4.38), having at least one general practitioner at the clinic devote significant time in practice to mental health (OR=1.54; 95% CI=1.07-2.21) and low perceived barriers to depression care due to inadequate payment models (OR=2.12; 95% CI=1.30-3.46).

CONCLUSIONS

Several primary care practice characteristics significantly influence the quality of care provided to patients with depression and comorbid chronic conditions and should be targeted in quality improvement efforts.

Physical comorbidity and 12-week treatment outcomes in Korean patients with depressive disorders: the CRESCEND study

OBJECTIVE

Physical and depressive disorders frequently co-occur, but effects of physical health on depression treatment outcomes have received little research. This study aimed to compare treatment outcomes between people with depressive disorder with and without comorbid physical disorders.

METHODS

A Korean nationwide sample of 723 people with depressive disorder initiated on antidepressant treatment, and re-evaluated at 1, 2, 4, 8, and 12 weeks later. Assessment scales for evaluating depressive symptoms (HAMD), anxiety (HAMA), global severity (CGI-s), and functioning (SOFAS) were administered at baseline and every follow-up visit. Achievement of remission or response was defined only when these were maintained to the 12 weeks study endpoint or to the last follow-up examination, if earlier, with the date of the first observed remission point applied as the timing of remission. Logistic regression and Cox proportional hazards models were used.

RESULTS

Of the sample, 247 (34%) had at least one physical disorder. This was associated with lower socioeconomic status and more severe depressive symptoms at baseline, but was not associated with any treatment related characteristics including antidepressant type and regimen, concomitant medications, side effects, and duration of treatment period. After adjustment, patients with physical comorbidity responded more slowly and less often - particularly in domains of anxiety, global severity, and functioning (all p-values <.005).

CONCLUSION

More intensive assessment and integrated treatment approaches are needed to facilitate treatment responses for depressive disorders in people with physical comorbidity. Future comparative studies between conventional and integrated treatment approaches are indicated for depressive disorders with physical comorbidity.

Effect of interventions for major depressive disorder and significant depressive symptoms in patients with diabetes mellitus: a systematic review and meta-analysis

BACKGROUND

Comorbid depression in diabetes is highly prevalent, negatively impacting well-being and diabetes control. How depression in diabetes is best treated is unknown.

OBJECTIVE

This systematic review and meta-analysis aims to establish the effectiveness of existing anti-depressant therapies in diabetes.

DATA SOURCES

PubMed, Psycinfo, Embase and Cochrane library. Study eligibility criteria, participants, interventions: randomized controlled trials (RCTs) evaluating the outcome of treatment by psychotherapy, pharmacotherapy or collaborative care of depression in persons with Type 1 and Type 2 diabetes mellitus.

STUDY APPRAISAL

risk of bias assessment; data extraction. Synthesis methods: data synthesis, random model meta analysis and publication bias analysis.

RESULTS

Meta analysis of 14 RCTs with a total of 1724 patients show that treatment is effective in terms of reduction of depressive symptoms: -0.512; 95% CI -0.633 to -0.390. The combined effect of all interventions on clinical impact is moderate, -0.370; 95% CI -0.470 to -0.271; it is large for psychotherapeutic interventions that are often combined with diabetes self management: -0.581; 95% CI -0.770 to -0.391, n=310 and moderate for pharmacological treatment: -0.467; 95% CI -0.665 to -0.270, n=281. Delivery of collaborative care, which provided a stepped care intervention with a choice of starting with psychotherapy or pharmacotherapy, to a primary care population, yielded an effect size of -0.292; 95% CI -0.429 to -0.155, n=1133; indicating the effect size that can be attained on a population scale. Pharmacotherapy and collaborative care aimed at and succeeded in the reduction of depressive symptoms but, apart from sertraline, had no effect on glycemic control.

LIMITATIONS

amongst others, the number of RCTs is small.

CONCLUSION

The treatment of depression in people with diabetes is a necessary step, but improvement of the general medical condition including glycemic control is likely to require simultaneous attention to both conditions. Further research is needed.