The lived experience of major and treatment-resistant depression in England: a mixed-methods study

INTRODUCTION

Major depressive disorder (MDD) is a common, frequently recurrent condition associated with decreased well-being and increased healthcare-related costs. Mixed-methods research provides multiple ways of illustrating the phenomenon to better understand patient experience, including where treatment is not working, referred to here as treatment-resistant depression (TRD).

METHODS

A mixed-methods study investigated the experiences of people with symptomatic MDD, symptomatic TRD or TRD in remission, surveying 148 adults recruited from English clinical sites to measure symptom severity (Patient Health Questionnaire-9 [PHQ-9]), HRQoL (EQ-5D-5L/World Health Organisation Brief Assessment of QoL [WHOQOL-BREF]) and work productivity/activity impairment (WPAI:D). Interviews with 26 survey respondents were analysed thematically. Integrated datasets explored areas of convergence and divergence, with concepts mapped against the EQ-5D-5L.

RESULTS

Qualitative data explained low WHOQOL-BREF domain scores and the interrelation of psychological, emotional, cognitive and physical difficulties. Tiredness, lack of energy and motivation impacted daily activities, socialising and career goals. Low work performance scores were explained by poor concentration, decision-making and motivation. Participants also described the influence of social support and housing insecurity. Only 19 % of HRQoL qualitative codes mapped to the EQ-5D-5L. Themes dominant in patients with TRD were inability to cope, self-care challenges, dissatisfaction with mental health services and treatment pessimism.

LIMITATIONS

Limited data collected on people with TRD in remission.

CONCLUSIONS

The EQ-5D-5L and WPAI:D likely underestimate how depression impacts the HRQoL and work of people with MDD or TRD. Qualitative data suggest increased distress for people with TRD compared to those with MDD. Clinical management and treatment access decisions should consider the broader impacts of depression and environmental factors affecting the patient's experience.

Health-related quality of life burden associated with treatment-resistant depression in UK patients: Quantitative results from a mixed-methods non-interventional study

BACKGROUND

Major depressive disorder (MDD) and its more intractable variant, treatment-resistant depression (TRD), are common conditions that adversely affect patient well-being and health-related quality of life (HRQoL). This study aimed to quantify the impact of MDD and particularly TRD on the HRQoL, functioning and productivity of UK patients to support clinical and reimbursement decisions and policymaking.

METHODS

148 patients with clinician-verified symptomatic (non-treatment-resistant) MDD (Patients-MDD; n = 61) or TRD (Patients-TRD; n = 87) were recruited from ten clinical sites. Participants completed validated patient-reported outcome measures assessing depressive symptom severity (Patient Health Questionnaire-9 [PHQ-9]), HRQoL (EQ-5D-5 L/abbreviated World Health Organization Quality of Life Questionnaire [WHOQOL-BREF]) and work productivity/activity impairment (WPAI:D).

RESULTS

Patients-TRD and Patients-MDD reported similar levels of depressive symptom severity (mean PHQ-9 16.2/16.6, respectively). However, HRQoL was significantly poorer for Patients-TRD compared with Patients-MDD, both in the overall cohort (median EQ-5D-5 L utility 0.606/0.721, respectively [p = 0.021]; WHOQOL-BREF overall score 55.2/58.8 [p = 0.024]) and in patients with a PHQ-9 score ≥15 (median EQ-5D-5 L utility 0.415/0.705, respectively [p<0.001]). Although a numerically lower proportion of Patients-TRD were employed (45% vs 57% of Patients-MDD; p = 0.204), employed Patients-MDD reported significantly higher absenteeism and work productivity loss.

LIMITATIONS

A minority of patients screened as having symptomatic MDD or TRD self-reported low PHQ-9 symptom severity. This was addressed with a subgroup analysis of patients with more severe depression.

CONCLUSIONS

TRD is associated with an added patient HRQoL burden, above that observed for non-treatment-resistant MDD. This highlights the unmet need for greater access to improved treatment, including new treatment options for Patients-TRD.

Maintaining Adherence Programme: evaluation of an innovative service model

Aims and method The Maintaining Adherence Programme (MAP) is a new model of care for patients with schizophrenia, schizoaffective disorder and bipolar affective disorder which aims to encourage adherence and prevent relapse. This evaluation, conducted by retrospective and prospective data collection (including patient questionnaires and staff interviews), aimed to describe MAP's impact on healthcare resource use, clinical measures and patient and staff satisfaction, following its implementation in a university National Health Service (NHS) foundation trust in England. We included 143 consenting patients who entered MAP before 31 March 2012. Results In-patient bed days and non-MAP NHS costs reduced significantly in the 18 months post-MAP entry. At 15-18 months post-MAP, Medication Adherence Rating Scale scores had improved significantly from baseline and there was a shift towards less severe clinician-rated disease categories. Based on patient surveys, 96% would recommend MAP to friends, and staff were also overwhelmingly positive about the service. Clinical implications MAP was associated with reduced cost of treatment, improvements in clinical outcomes and very high patient and staff satisfaction.

The management and outcomes of fingolimod first dose cardiac monitoring in UK patients with relapsing-remitting multiple sclerosis

BACKGROUND

Patients initiated on Gilenya (fingolimod) require cardiovascular monitoring for 6h after the first dose. Novartis has engaged an independent provider (Regent's Park Heart Clinics [RPHC]) to provide a first dose observation (FDO) service to UK neurologists.

OBJECTIVES

To describe routinely-documented clinical observations (heart rate [HR], blood pressure [BP], cardiac rhythm [CR]) and outcomes from the RPHC fingolimod FDO service.

METHODS

Pseudonymised data (clinical observations pre-dose and for 6h after the first dose and any requirement for extended monitoring) were collected retrospectively from RPHC records for the first 850 RPHC FDO episodes (undertaken Jul-2012 to Jan-2015). All episodes involved patients with relapsing-remitting MS who were initiated on fingolimod in routine National Health Service (NHS) clinical practice.

RESULTS

In 78% of FDO episodes the patient was female. Mean age at date of episode was 40.1 years. Mean HR was 72.7 bpm (beats per minute) pre-dose, 64.3 bpm at 5h (the lowest recorded HR) and 66.1 bpm at 6h post-dose. New-onset heart block was observed in 2% of episodes (1.5% first-degree; 0.5% second-degree). The patient was discharged at 6 hours post-dose in 97% of episodes and required extended monitoring in 3%. In 5 episodes overnight monitoring was required. There were no episodes in which the patient required pharmacological intervention or temporary cardiac pacing.

CONCLUSIONS

In this real-world UK population fingolimod initiation was predominantly uneventful; clinical observations were similar to previous clinical trials.

Retrospective case note review of chronic spontaneous urticaria outcomes and adverse effects in patients treated with omalizumab or ciclosporin in UK secondary care

BACKGROUND

Omalizumab is approved in the UK as add-on treatment for chronic spontaneous urticaria (CSU) in patients with inadequate response to H1-antihistamines. Ciclosporin is an established but unlicensed 3rd line option for CSU. Two parallel retrospective observational studies were conducted to describe outcomes of treatment and adverse events with omalizumab or ciclosporin for CSU treatment.

METHODS

Data from UK specialist centres prescribing omalizumab (five centres) or ciclosporin (three centres) in CSU patients were collected from hospital records by clinical staff and pooled for analysis.

RESULTS

Forty-six patients prescribed omalizumab and 72 patients prescribed ciclosporin were included. Twenty-two (48%) omalizumab-treated patients had paired Urticaria Activity Scores (UAS7), showing a 25.4 point improvement during treatment (P < 0.0001). Paired Dermatology Life Quality Index (DLQI) was available in 28 (61%) omalizumab-treated and 17 (24%) ciclosporin-treated patients. At least a 75% improvement in DLQI score was observed in 79% of omalizumab-treated and 41% of ciclosporin-treated patients, and 65% of omalizumab-treated patients had complete resolution of their quality-of-life impairment (DLQI 0-1) versus 21% of ciclosporin-treated patients. Clinician comments reported symptom clearance in 15/36 (42%) omalizumab-treated and 10/60 (17%) ciclosporin-treated patients. Proportions of patients with adverse events were similar but those for omalizumab resembled CSU symptoms, making causality assignment difficult, whereas those for ciclosporin were consistent with its known adverse effect profile.

CONCLUSIONS

Validated patient-reported measures of disease severity and quality of life should be used routinely in CSU management. Based on clinician comments and DLQI scores, symptoms and quality of life showed a greater improvement in the omalizumab-treated cohort than in the ciclosporin-treated cohort.

Comparing post-operative resource consumption following transcatheter aortic valve implantation (TAVI) and conventional aortic valve replacement in the UK

OBJECTIVE

To define the in-hospital and 6-month post-discharge resource use, following Transcatheter Aortic Valve Implantation (TAVI) and conventional Aortic Valve Replacement (AVR) surgery within a single UK hospital.

METHODS

A local service evaluation of patients undergoing TAVI or AVR between January 2011 and May 2012 captured data until 6-months post-procedure, collected from hospital records and via a General Practitioner questionnaire. The main end-points were mortality, time in ITU/HDU, hospital length of stay (LoS), discharge destination, re-admission, and post-discharge primary/secondary care resource use. Sub-group analyses were performed for AVR patients aged ≥80 (AVR ≥ 80) and with EuroSCORE of ≥10 (AVR ES ≥ 10) to allow more direct comparison with 'TAVI type' patients.

RESULTS

Results are given as means (standard deviation) for TAVI (n = 51), AVR (n = 188), AVR ≥ 80 (n = 48), and AVR ES ≥ 10 (n = 47), respectively, unless otherwise stated. Age in years was 83.0 (8.1), 71.2 (13.1), 84.1 (2.7), 79.4 (7.1); EuroSCORE was 24.7 (11.9), 8.1 (6.4), 12.0 (6.0), and 16.5 (6.6); post-operative LoS (days) was 11.5 (11.2), 10.9 (10.8), 14.3 (16.7), and 15.2 (17.7). For discharged patients, 0%, 7%, 13%, and 9% had unplanned cardiac-related re-admissions within 30-days of discharge. Time to first readmission was 74.6 (34.0), 35.0 (34.2), 20.8 (9.7), and 22.6 (14.3) days.

LIMITATIONS

This was a single-center retrospective evaluation, not prospectively powered to confirm differences in outcomes.

CONCLUSIONS

Despite TAVI being performed in an older, higher risk population, LoS was similar to AVR. Most strikingly there were no cardiac-related re-admissions within 30-days for TAVI and time to first re-admission was significantly longer. This evaluation suggests that TAVI is clinically appropriate and provides economic advantages in both the hospital and post-discharge setting in this high risk group. Many patients undergoing TAVI are considered unfit for surgery and, hence, TAVI offers a treatment that delivers similar results to traditional AVR without the high risk associated with surgery.

The non-anticoagulation costs of atrial fibrillation management: findings from an observational study in NHS Primary Care

Background:

Atrial fibrillation (AF) management represents a significant burden on the UK NHS. Understanding this burden will be important in informing future health care planning and policy development.

Aim:

To describe the non-anticoagulation costs associated with AF management in routine UK clinical practice.

Materials, patients and methods:

A retrospective observational study of 825 patients with AF undertaken in eight UK primary care practices. Data collected from routine clinical and prescribing records of all eligible, consenting patients, for a period of up to 3 years. The first 12 weeks following diagnosis was defined as the ‘initiation phase’; the period after week 12 was defined as the ‘maintenance phase’.

Results:

Mean (SD) total cost of AF management was £941 (£1094) per patient in the initiation phase and £426 (£597) per patient-year in the maintenance phase. AF-related inpatient admissions contributed most to total costs; the mean (SD) total cost per patient in the initiation phase was £2285 (£900) for admitted and £278 (£252) for non-admitted patients. Mean maintenance phase costs per year were £1323 (£755) and £168 (£234), respectively, for admitted and non-admitted patients. Significant patient variables contributing to high cost in the initiation phase were hypertension and younger patient age, although only accounting for 6% of cost variability. Significant variables in the maintenance phase (18% of cost variability) were the presence of congestive heart failure, structural heart disease or diabetes and the frequency of day case admissions, ECGs and hospitalisations in the initiation phase.

Conclusions:

Inpatient admissions contributed most to total AF management costs. Given the burden of hospital care, future work should focus on evaluating the appropriateness and reasons for hospitalisation in patients with AF and the factors affecting length of stay, with the aim of identifying opportunities to safely reduce inpatient costs.

A number of significant patient characteristics and initiation phase variables were identified, which accounted for 18% of the variability in total maintenance phase costs. However, none of these could adequately predict high maintenance phase costs.

The synthesis of symmetrical spermine conjugates using solid-phase chemistry

The utility of spermine, selectively functionalised and immobilised on a solid support by means of the Wang "oxycarbonyl" linker is demonstrated by the solid-phase synthesis of a number of spermine conjugates including the natural product and potent antihypertensive agent kukoamine. The synthesis opens up the area of solid-phase spermine chemistry and library generation based on the symmetrical spermine scaffold.