Performance Improvement - Depression

Major depressive disorder (MDD) is a common and greatly debilitating illness that affects as much as 13% of the U.S. population, with each depressive episode lasting approximately 16 weeks. It imposes a substantial burden on society as a leading cause of disability, lost work productivity, morbidity, mortality, and increased use of health services.

Until recently, response, defined as a 50% or greater reduction on objective measures of improvement such as HAM-D or CGI-I, was the focus of treatment. Now, however, treatment success in the management of MDD is determined by meeting two goals: 1) complete relief from all signs and symptoms of depression, including the restoration of psychosocial and occupational functioning to premorbid levels; and 2) complete symptomatic remission or prevention of recurrence.

Patients treated for MDD who still have residual symptoms have more than twice the risk of relapse and experience a recurrence more than 3 times faster than asymptomatic patients. This highlights the need for MDD to be adequately treated and monitored over time to ensure that patients achieve and maintain remission of all symptoms. Subsequently, in order to achieve remission and long-term functional recovery in patients with MDD, it is critical to have the skills to develop and implement effective treatment plans.

References:

1. Hasin DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of major depressive disorder: results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Arch Gen Psychiatry. 2005;62(10):1097-1106.
2. Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289(23):3095-3105.
3. Rush AJ, Trivedi MH. Treating depression to remission. Psychiatr Annals. 1995;25:704-705.
4. Panzarino PJ, Jr. The costs of depression: direct and indirect; treatment versus nontreatment. J Clin Psychiatry. 1998;59 (suppl 20):11-14.
5. Thase ME. Therapeutic alternatives for difficult-to-treat depression: a narrative review of the state of the evidence. CNS Spectr. 2004;9(11):808-816, 818-821.
6. Miller IW, Keitner GI, Schatzberg AF, et al. The treatment of chronic depression, part 3: psychosocial functioning before and after treatment with sertraline or imipramine. J Clin Psychiatry. 1998;59(11):608-619.
7. Halfin A. Depression: the benefits of early and appropriate treatment. Am J Manag Care. 2007;13:S92-S97
8. Trivedi MH. Treatment-resistant depression: new therapies on the horizon. Ann Clin Psychiatry. 2003;15(1):59-70
9. Rush AJ, Trivedi MH, Wisniewski SR et al. Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression. N Engl J Med. 2006;354 (12):1231-1242
10. Rush AJ, Trivedi MH, Wisniewski SR, Nierenberg AA et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry. 2006;163(11):1905-1917

Performance Improvement - Schizophrenia

Schizophrenia is a highly prevalent disorder that continues to challenge physicians with respect to diagnosis and treatment. It has been reported that, on average, individuals diagnosed with schizophrenia suffered with the condition for more than 2 years before a correct diagnosis and intervention was made. Numerous factors lead to misdiagnosis including symptom overlap between the different syndromes, challenges with diagnostic criteria, and comorbid medical and psychiatric conditions.

Early onset and a course of chronic and recurrent relapses and hospitalizations are central features of schizophrenia. The age of onset of the disorder is widely accepted as carrying considerable clinical and prognostic significance. Patients with early age of onset are likely to have worse premorbid functioning, a significantly longer duration of untreated psychosis, more severe illness, and a greater likelihood of biological abnormalities. Proponents of early intervention argue that outcome may be improved if more therapeutic efforts were focused on the early stages of schizophrenia. Moreover, as approximately half of patients with schizophrenia have at least one comorbid psychiatric or medical condition, prognosis is worsened and morbidity and mortality is increased. Many patients with comorbid conditions experience limited functionality, and the presence of comorbidity leads to poorer short- and long-term outcomes in schizophrenia, and complicates the treatment of both schizophrenia and co-occurring conditions.

Long-term therapy is a necessary requirement for most patients with schizophrenia, however, effective treatments that maintain efficacy with minimal adverse effects can be a difficult balance to achieve. Subsequently, in order to mitigate the effects of the chronic, debilitating nature of schizophrenia, clinicians must be able to recognize the disorder in its prodromal phase and develop strategies to implement aggressive, appropriate care unique to each patient’s dynamics.

References

1. Perkins DO, Leserman J, Jarskog LF, et al. Characterizing and dating the onset of symptoms in psychotic illness: the Symptom Onset in Schizophrenia (SOS) inventory. Schizophr Res. 2000; 44(1):1-10.
2. Yung AR, McGorry PD. The initial prodrome in psychosis: descriptive and qualitative aspects. Aust NZJ Psychiatry. 1996;30(5):587-599.
3. Ziedonis DM, Smelson D, Rosenthal RN et al. Improving the care of individuals with schizophrenia and substance use disorders: consensus recommendations. J Psychiatr Pract. 2005 Sep;11(5):315-39
4. Colton CW, Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chronic Dis. 2006;3:A42.
5. Ongur D, http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Ong%C3%BCr%20D%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlusLin L, Cohen BM. Clinical characteristics influencing age at onset in psychotic disorders. Compr Psychiatry. 2009;50:13–19.
6. Joa I, Johannessen JO, Langeveld , et al. Baseline profiles of adolescent vs. adult-onset first-episode psychosis in an early detection program. Acta Psychiatr Scand. 2009;119:494–500.
7. Marshall M, Rathbone J. Early intervention for psychosis. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD004718.
8. Nasrallah HA, Keshavan MS, Benes FM, et al. Proceedings and data from The Schizophrenia Summit: a critical appraisal to improve the management of Schizophrenia. J Clin Psychiatry. 2009;70 Suppl 1:4-46.
9. Chwastiak L, Rosenheck R, McEvoy JP et al. Interrelationships of Psychiatric Symptom Severity, Medical Comorbidity, and Functioning in Schizophrenia. Psychiatr. Serv. 2006. 57(8):1102-1109
10. Batki SL, Meszaros ZS, Strutynski K et al. Medical comorbidity in patients with schizophrenia and alcohol dependence. Schizophr Res. 2009 Feb;107(2-3):139-46.