Measurement-Based Care

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Measurement-Based Scales In Major Depressive Disorder: Implementing Patient-Reported Outcome Scales With The Goal Of Improving Treatment Outcomes

During this recorded presentation, Mark Zimmerman, MD, provided a brief overview of measurement-based scales and implementing patient-reported outcome scales (PROS) with the goal of improving treatment outcomes. Key points included:

• The benefits of measurement-based care in the treatment of depression
• Patient-reported outcome scales (PROS) can help identify unresolved symptoms of depression and may improve depression treatment outcomes
• The use of PROS is accepted by patients and scales are easily accessible

An Overview Of The Clinically Useful Depression Outcome Scale (CUDOS)

During this recorded presentation, Mark Zimmerman, MD, provided a brief overview of the Clinically Useful Depression Outcome Scale (CUDOS), a measure that was developed to assess the course of depression and the severity of depressive symptoms. Key points included:

• Review of the Clinically Useful Depression Outcome Scale (CUDOS)
• Patient Acceptability of Measurement-based Care
• Validity of Self-report Severity Subtyping with the CUDOS

Using Measurement Strategies to Identify and Monitor Residual Symptoms

Key Messages

• Many patients treated for major depressive disorder (MDD) continue to have residual symptoms after acute treatment with pharmacotherapy.
  • Cognitive dysfunction, which plays an important role in functional outcome, is one of the most common residual symptoms in MDD.
• Patients with residual symptoms may need additional treatment interventions such as switching to another antidepressant, combining antidepressants, or adding another agent to the existing antidepressant.
• Measurement-based care involves using objective tools to quantify the presence and severity of depressive symptoms/adverse events and measure functional outcomes. Incorporation of measurement-based care has been shown to improve patient outcomes in MDD.
  • The author noted that by carefully monitoring symptomatology with measurement tools, clinicians might be able to determine within 4 to 6 weeks, or even earlier, whether treatment modification is needed.

Background & Purpose

The following is a summary of McIntyre RS. Using measurement strategies to identify and monitor residual symptoms. J Clin Psychiatry. 2013;74[Suppl 2]:14−18, which was developed independently of the article author.

• Current therapeutic goals in MDD focus on full symptomatic remission and functional recovery. However, despite substantial progress in the treatment of MDD, many patients do not achieve full remission after pharmacotherapy.
• Symptomatic remission has been shown to increase a patient’s chance of functional recovery, whereas incomplete remission increases the risk of relapse, recurrence, and a chronic course of depression. Furthermore, the presence of residual symptoms increases a patient’s use of health care services and risk of suicide.

This review article discussed the impact of residual symptoms, in particular cognitive impairment, in patients treated for MDD, and reviewed additional treatment interventions for patients with residual symptoms, as well as the use of measurement-based care to improve patient outcomes.

Methodology & Results

The author broadly reviewed research on residual symptoms in depression; no specific details of methodology were reported in the paper.

Regarding measurement-based care

• Measurement-based care is defined as the use of objective tools to quantify the presence and severity of depressive symptoms, measure functional outcomes, and determine the severity of adverse events.
  • Measurement-based care incorporates the use of screening tools to determine whether to conduct a full diagnostic evaluation, diagnostic tools to enable a precise diagnosis of MDD, symptom severity tools to monitor depressive symptomatology over time, and tools to track side effects of treatment.
  • For patients with MDD, measurement-based care appears to improve the likelihood of remission, treatment persistence, and functional recovery.

Regarding residual symptoms and cognitive dysfunction in MDD

• Common residual symptoms in patients treated for MDD include fatigue, sleep problems, and cognitive impairment.
• Depression adversely affects cognitive domains such as memory, executive function, attention, and information processing speed.
• Research suggests that cognitive dysfunction is a principal mediator of functional impairment in MDD and can impact treatment adherence and suicidal ideation, though it has historically received less research attention than mood or somatic alterations.
• Cognitive dysfunction is one of the most common residual symptoms in MDD.
  • Cognitive impairment was present in 94% of patients with MDD in a 3-year prospective study, and residual cognitive dysfunction was reported in 44% of patients whose depression remitted.
  • Residual cognitive dysfunction may predict depression recurrence, and in some patients with MDD, cognitive impairment may worsen over successive episodes of depression.

Regarding antidepressant therapy and cognitive performance

• The author described two studies that examined the effect of antidepressant therapy on cognition in patients with MDD (see Table 1).

Table 1.

Patient group	Treatment	Outcome measures	Results
Patients ≥65 years with recurrent MDD	Serotonin-norepinephrine reuptake inhibitor vs placebo	· Verbal Learning and Recall Test · Symbol Digit Substitution Test · Two-Digit Cancellation Test · Letter-Number Sequencing Test · Composite score across all 4 tests	· Improvement in composite test score (p<0.02) · Improvement in learning (p=0.003) and memory (p=0.02) in the Verbal Learning Test
Older adults with recurrent MDD	Atypical antidepressant vs placebo	· Not reported	· Significant improvements in measures of learning, memory, and information processing speed (no p-value was reported)

Regarding modifying treatment

• Measurement-based care can help clinicians decide whether MDD treatment has been effective, or if further intervention is needed.
  • For patients showing an early lack of improvement, evidence-based and consensus-based guidelines generally recommend switching to another antidepressant, combining antidepressants, or adding another agent within the first 4 to 8 weeks of treatment.
  • The author noted that the addition of atypical antipsychotics to antidepressant therapy has been the most thoroughly studied augmentation approach.
    • Meta-analytical data indicate that this approach is more effective than antidepressants plus placebo in reducing depressive symptoms (p<0.00001), though adverse effects of atypical antipsychotics may be problematic.

Conclusions & Clinical Implications

• Many patients with MDD do not achieve full symptomatic remission, increasing the risk of relapse, recurrence, and a chronic course of depression.
• It has been suggested that cognitive dysfunction, one of the most common residual symptoms in treated patients, is a principal mediator of functional impairment in MDD.
• Measurement-based treatment has been shown to improve patient outcomes in MDD.
  • Patients with residual symptoms may require additional treatment intervention. Careful monitoring of symptomatology may allow clinicians to determine within 4 to 6 weeks of treatment whether treatment modification, such as switching to another antidepressant, combining antidepressants, or adding another agent to the existing antidepressant, is necessary.
• Many patients treated for MDD will have residual symptoms, with cognitive dysfunction being one of the most common. As cognitive problems significantly affect patients’ functioning and treatment adherence, the author suggested that clinicians make resolution of cognitive symptoms an important therapeutic objective.

Disclosures

This summation has been developed independently of the author. The following disclosures were reported in the original article: “Dr McIntyre has served on the advisory boards for AstraZeneca, Bristol-Myers Squibb, Eli Lilly, France Foundation, GlaxoSmithKline, Janssen-Ortho, Lundbeck, Merck, Organon, Pfizer, and Shire; has served on the speakers bureaus for AstraZeneca, Eli Lilly, Janssen-Ortho, Lundbeck, Merck, and Pfizer; has received grant/research support from AstraZeneca, Eli Lilly, Janssen-Ortho, Lundbeck, the National Alliance for Research on Schizophrenia and Depression, the National Institutes of Mental Health, Pfizer, Shire, and the Stanley Medical Research Institute; and has participated in CME activities for AstraZeneca, Bristol-Myers Squibb, CME Outfitters, Eli Lilly, France Foundation, I3CME, Merck, Optum Health, and Pfizer.

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