Clinical trials of antidepressants: time to shift to a new model

Improving the assessment of depression remission with the Remission Evaluation and Mood Inventory Tool

OBJECTIVE

The Remission Evaluation and Mood Inventory Tool (REMIT) is a practical 5-item self-report measure of key positive mood states associated with recovering from depression, as distinct from depressive symptoms per se. The study goal was to identify a clinically useful threshold for interpreting REMIT responses in the context of mild to moderate depressive symptoms.

METHODS

This was a secondary analysis of a cross-sectional dataset initially used to develop and validate the REMIT. Primary care patients being treated for depressive symptoms of either mild or moderate severity (n = 247 and 240, respectively) rated their perceived degree of depression remission prior to completing the Patient Health Questionnaire-8 (PHQ-8) and the REMIT. We summed the totals of the latter two measures to form the PHQ + REMIT index.

RESULTS

Receiver Operating Characteristics analysis indicated that the PHQ + REMIT threshold ≥ 13 was associated with good sensitivity (92%) and acceptable specificity (43%) to the absence of patient-perceived remission. In contrast, the PHQ had only 21% specificity at this sensitivity level. Area under the curve was 0.815 (95% C.I.: 0.765-0.865), which was significantly greater than that of the PHQ-8 alone (area under the curve = 0.745, 95% C.I.: 0.691-0.805, p(diff) = 0.0002). Threshold performance was unaffected by adjustment for demographic characteristics and variation in remission percentage. Compared with standard symptom-based classification, using the REMIT reclassified 27% of mildly symptomatic patients as remitted.

CONCLUSIONS

Using the REMIT with patients who have mild to moderate depressive symptoms improves the assessment of patient-perceived remission, which is indicated by a summed PHQ + REMIT index of less than 13. Longitudinal research is needed to test whether this broadened patient-centered approach to assessing remission improves clinical decision making and long-term outcomes.

Toward a more comprehensive assessment of depression remission: the Remission Evaluation and Mood Inventory Tool (REMIT)

OBJECTIVE

Depression remission continues to be defined in terms of resolution of the Diagnostic and Statistical Manual of Mental Disorders criteria symptoms. However, it may be useful to assess additional symptoms as part of a more complete evaluation of remission. We sought to develop an adjunct self-report measure that can be used with commonly used depression measures when assessing remission.

METHODS

Secondary data analysis and expert input were used to develop candidate items that were evaluated cross-sectionally in 1003 primary care clinician-identified depressed patients from two practice-based research networks. Multivariable regression analysis, with self-assessed recovery as the dependent variable, identified five symptoms that contributed significantly beyond the Patient Health Questionnaire (PHQ)-8. Further analysis was performed in selected subsamples.

RESULTS

Emotional control, contentedness, future seeming dark, ability to bounce back and happiness yielded an 11% increase in R(2) beyond 60% yielded by the PHQ-8. The summed Remission Evaluation and Mood Inventory Tool (REMIT) 5 items have a mean=9.6 (S.D.=4.5), range 0-20 and reliability of 0.86. Subsample analysis showed incremental R(2) ranging from 9% in men to 15% in African-Americans.

CONCLUSION

Depression remission is a multidimensional concept that includes important nondepressive symptom dimensions. These important dimensions can be measured using a self-report instrument feasible for routine primary care. Pending longitudinal validation, REMIT5 is a promising tool for depression management.