Beyond symptom reduction and towards engagement with life

Enhancing engagement with life is a key target of treatment in MDD and extends beyond symptom control. “Patient Life Engagement” encompasses outcomes that reflect life fulfillment, well-being, and participation in valued and meaningful activities and can be measured using a subscale based on the Inventory for Depressive Symptomatology.1,2

Efforts to hear the voice of depressed patients highlight the need for appropriate assessment of patient-centered treatment goals.1

Outcomes reflecting life fulfillment, well-being, and participation in valued and meaningful activities are encompassed by the term “patient life engagement”,2  and enhancing patients’ engagement with life should be a key target of treatment, Melissa Paulita Mariano (University of East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines)  told a satellite symposium at CINP Virtual 2021.

 

Enhancing life engagement a key future aim

We can’t assume that patients with symptomatic remission have a satisfactory quality of life or level of functioning, she said. Many treatments fail to address the full spectrum of symptoms and functional deficits extending beyond symptoms that prevent patients from achieving fulfilling lives.3,4   

 We need to address functional deficits that extend beyond symptoms

In the acute phase of major depressive disorder (MDD), the goals of healthcare professionals (HCPs) do not entirely match those of patients, according to a recent study.5 While 53% of HCPs said lifting mood was their primary aim, only 29% of patients said that this best reflected their hopes. For the majority of patients, a return to family, social and working life was their priority.5

 

Impact of inadequate response underestimated

Inadequate response to initial antidepressant therapy (ADT) is common, can significantly impair functioning, and causes frustration.6

Response rates to ADT in general have not improved for many years,7,8 and HCPs may underestimate the impact. In a 2018 survey, psychiatrists judged that 11% of patients were frustrated by their medication.9  Yet, in the same year, 29.8% of more than two thousand patients with inadequate response to ADT  expressed frustration, and 27.4% felt hopeless.6

In the STAR*D study, sequential treatments had a progressively smaller effect on quality of life10 and patients who did not achieve remission were less likely to achieve a normal quality of life.

 

Demonstrated efficacy of adjunctive therapy  on symptoms

Interest in subjective outcomes has grown and the concept of success has evolved. In this context, adjunctive treatment with an antipsychotic may improve outcomes, Michael Thase (Perelman School of Medicine of the University of Pennsylvania, USA) said.7

For patients with inadequate response to antidepressant monotherapy, professional bodies (including the American Psychiatric Association and the UK National Institute for Health and Care Excellence) have moderate to substantial clinical confidence in antipsychotics as adjunctive treatment.11-14 D2 receptor partial agonists are among these agents, Professor Thase noted.13

In the adjunctive treatment of MDD after failure of monotherapy, second-generation antipsychotics have achieved rates of response and remission significantly higher than placebo.15 Efficacy against depressive symptoms has been demonstrated.16 Yet many patients continue to experience functional impairment despite adjunctive therapy.17

 

Benefits beyond symptom control

So there is a need for treatments that achieve benefits beyond symptom control and enable patients to engage with family, social, and work life, Professor Thase argued.

Patient life engagement encompasses outcomes that reflect fulfillment, wellbeing, and participation in valued and meaningful activities

Roger McIntyre (University of Toronto, Canada) further explored the concept of “patient life engagement” that encompasses outcomes reflecting life fulfillment, wellbeing, and participation in valued and meaningful activities.  

 

Response rates were higher with adjunctive therapy than with placebo, and this was associated with improved functioning.17,19 And, crucially, improved patient life engagement was associated with improved functioning.19

 

 

QoL : Quality of life 
MDD: Major Depressive Disorder 
CINP: The International College of Neuropsychopharmacology 
ADT : antidepressant therapy 
HCP: Health Care Professional
STAR*D: Sequenced Treatment Alternatives to Relieve Depression 
UK : United Kingdom

 

2021 BE-NOTPR-0049; approval date 9/2021

 

Educational financial support for this satellite symposium at CINP Virtual 2021 was provided by Otsuka and H. Lundbeck A/S

Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.

References

1. McCue et al. Neurol Ther 2019;8(2):167-76

2. Bartrés-Faz et al. Alzheimers Res Ther 2018;10(1):47

3. Forray and Buller. Biochem Pharmacol 2017;143:10–24  

4. Zipursky et al. Schizophr Bull 2013;39(6):1363–1372 

5. Baune and Christensen. Front Psychiatry 2019;10:33

6. Mago et al. BMC Psychiatry 2018;18(1):33

7. Han et al. Expert Rev Neurother 2013;13(7):851–870

8. Papakostas & Fava. Eur Neuropsychopharmacol 2009;19(1):34–40

9. Mago et al. Ann Gen Psychiatry 2018;17:20 

10. IsHak et al. Acta Psychiatr Scand 2015;131(1):51–60

11. Cleare et al. J Psychopharmacol 2015;29(5):459–525

12.  Bauer et al. World J Biol Psychiatry 2013;14(5):334–385

13.  Kennedy et al. Can J Psychiatry 2016;61(9):540–560

14.  Parikh et al. Can J Psychiatry 2016;61(9):524–539

15.  Papakostas et al. J Clin Psychiatry 2007;68(6):826–831  

16.  Zhou et al. Int J Neuropsychopharmacol 2015;18(11):pyv060

17.  Weiller et al. Neuropsychiatr Dis Treat 2018;14:103–115  

 

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