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Major Depressive Disorder – where are we falling short?

Posted in Sponsored Feature on 23rd Jul 2020

Professor Major Depressive Disorder - sponsored by JanssenRamin Nilforooshan, Consultant Psychiatrist, Surrey and Borders Partnership NHS Foundation Trust, University of Surrey

At any one time, one in six adults are affected by mental ill health, with the burden of disease estimated to cost £105 billion a year in England alone.[i] There is no question that this is a field that urgently needs our attention.

In particular, major depressive disorder (MDD), which refers to severe and persistent symptoms of depression, is taking a devastating toll, causing significant ill-health, disability and suffering for patients and their families, as well as an incredible strain on our healthcare system and economy.[i],[ii],[iii] Depression affects all aspects of a person’s life, physically, socially and emotionally. Consider the multifaceted effects of suicide, the long-lasting impact on physical health (depression is a major contributor to coronary heart disease), and the fact that so many patients simply don’t remember what it means to be happy.[i]

It is clear this is a significant problem. But is it being addressed? Is access to care for mental health equal to that for physical health? The answer is no.

Mental illness is the largest single cause of disability, representing 23 percent of all ill-health in the UK. Yet only 13.8 percent of England’s health budget is spent on mental health.[iv]

Without the resources, the majority of such services are struggling to provide better services, and although we’ve opened up the debate on parity of esteem in recent years, much more needs to be done. The voice of the patient is one of the strongest factors in improving and expanding services, and unfortunately, those with MDD and other conditions just don’t have the energy or motivation. We must, as a collective, take this into our own hands and take responsibility for our patients.

The difficulty with diagnosis

The first step towards effective treatment is the right diagnosis. Yet, for MDD, this is confounded by multiple factors. Unfortunately, our first and immediate issue is that patients are not so willing to open up about their mental health.

Despite celebrity outreach and campaigns like Time to Change, launched in 2007, there is still a big mental health stigma in the UK stopping people getting the help they need.[v] It is both a social problem, meaning friends and family might not push individuals to see a clinician, and a personal one – if they do go, they’re likely to claim a headache, back pain, or that they can’t sleep.[vi] To add to the issue, patients’ willingness to divulge information is compromised by their MDD.[vii]

Patients are also commonly deterred by negative experiences with healthcare professionals and are worried they won’t get taken seriously.5 This is sadly understandable – UK GPs have reported feelings of ambivalence in working with depressed people, a lack of confidence in their ability to manage the condition with the options available, and a belief that some patients will feel stigmatised by a diagnosis of depression.[viii],[ix] The end result is that many patients do not seek early help, and it can instead take them years to seek out.[x] As few as a quarter of adults with depression or anxiety receive treatment in the UK.[xi]

So, we can’t leave it all to patients and charities. Our responsibility, as clinicians, and the public health service, is to make sure that we are as prepared as possible to spot MDD even in the midst of stigma. How might we do that?

Currently in the UK, around 90 percent of those with mental health disorders are diagnosed and managed in primary care, and almost one-third of GP appointments involve an underlying mental health component.[xii] Yet GPs only have, on average, just over nine minutes to make their diagnosis and only a small fraction of that consists of actual eye-to-eye contact.[xiii],[xiv] In addition, one study found that fewer than half of trainee GPs had undertaken training in a mental health setting.[xv]

But when time is limited, proactive education is critical. We all need to know the guidelines, receive the relevant updates, and know what to look for and what questions to ask in that crucial time. The information is out there already. Right now, a diagnosis of MDD requires two of the cardinal features of depression, plus five additional features that represent a distinct change from previous functioning, for a continuous period of 14 days.[xvi],[xvii] The key word here is function; MDD affects someone’s global functioning, from their work, to their relationships, to their day-to-day-activities. It is their whole life. That’s why it’s so important to be able to spot it.

The right treatment, at the right time

Unfortunately, mental health treatment often falls very short of the standards for physical health. In physical health, clinicians aim for full recovery, but frequently this is not the case with MDD. We need to be aiming for full recovery of function, not just some improvement in some symptoms, or to ‘just coping’. If we don’t get our patients back to their full function, can we really say their treatment is complete?

It is therefore crucial that we treat our patients effectively, and as early as we can. Both prospective and retrospective studies have found that the sooner MDD is treated, the better the long-term outcomes, and earlier optimisation can prevent long-term suffering and help avoid inpatient treatment.[xviii],[xix]

Right now, the majority of patients with depression are treated with medications or psychological therapy (talking Therapy). Yet it shouldn’t have to be one or the other – in fact, NICE guidelines recommend a combination for those with moderate or severe depression.[xx] If a patient feels they would benefit from both, shouldn’t that be an option?

We need to weigh up what is best for our patients – and then continue to assess them regularly. NICE recommends reviewing patients two weeks after prescription, identified as the optimal point to evaluate early improvement and predict the likelihood of remission in the next 10 weeks.[ix],[xxi] If a lack of response is evident, the patient should continue to be evaluated after three to eight weeks, and if their depression is complex and severe, they must be referred to a specialist mental health service.[ix],[xix]

If they aren’t showing the right results after those two weeks – i.e. an improvement in functioning – the dose or the treatment needs to be changed. At the moment, however, studies suggest this is not happening. One study found that 48 percent of patients with at least moderate MDD received no treatment despite exhibiting all relevant symptoms to warrant initiation of antidepressant therapy. Of those who did receive treatment, 84 percent failing to respond to their current medication had no change in therapy for at least 8 weeks, and were treated for an average of 37 weeks with the same drug.[xix]

Numbers like these are shocking, but sadly the reality. We must act quickly and be proactive if we want the best for our patients. We must improve training for clinicians, so they stay up to date, and know which treatment is best according to guidelines.

The attitude of clinicians needs to change, and we need better access to a range of resources. Some areas hold promise; in secondary care, for example, patients are offered a wider range of medications and a more holistic approach to treatment akin to many physical therapy areas. The Improving Access to Psychological Therapies (IAPT) programme, which began in 2008, is also making a difference. Its aim is to offer evidence-based therapy, routine monitoring, and regular supervision, so clinicians have the right support to continually improve their service offering. The NHS has committed to allowing 1.9 million people a year access to this programme by 2023/4.[xxii]

How can technology help us?

It’s one thing to say that if something isn’t working, we should change it, or step it up. But how do we know if a treatment is working or not? How do we know if a patient is improving?

Unfortunately, there aren’t many biomarkers when it comes to MDD. Clinical interviews, while important, are subjective and hard to compare when patients switch between clinicians. We need a more generalised measurement that excludes human bias.

Artificial intelligence (AI) and machine learning could have a big role to play in improving the treatment of depression. While the application of AI is improving, clinical health still lags behind other fields, potentially because of a reluctance to use such technology when people’s lives are involved – but the possibilities to advance care are extraordinary. Apps and passive monitoring systems could gather more in-depth and longer-term data on how our patients are coping. Their walking speed, the angle of their neck (related to eye contact), the quality of their sleep, the tone of their voice, their activity per day (step count) – all of this could be analysed with machine learning to chart improvements with treatment in ways that humans simply cannot.[xxiii]

Technology may seem scary, and while it cannot replace real, human interaction, if used correctly, it could help a great deal. Using such a system could even help patients be seen when they actually need to be seen – by monitoring and then calling them on the day – while those that can, avoid the discomfort of an unnecessary appointment. This kind of system could truly help us to do more for our patients.

The system needs to change

Improving access to mental health treatment is everyone’s responsibility, and the health economy has a massive part to play.

Funding is currently a big issue. The Quality and Outcomes Framework (QOF) scheme offers significantly fewer incentives for mental health compared to physical health – another sign that parity of esteem has a long way to go in the UK. Measurements aren’t the same, and clinicians need to spend double the time for those with mental illness as they do with physical illness. That should be considered; we need a fairer way of incentivising treatment for mental health vs physical health.

As for new treatments, they are hard to come by compared with other therapy areas. The total expenditure on mental health research from 2014–17 was £497 million, on average £124 million per year. These figures translate to just over £9 spent on research per year, for each person affected by mental illness. By comparison, £612 million is spent on cancer research each year, which translates to £228 per person affected – or 25 times more per person.[xxiv]

Clinical trials are often delayed because of recruitment and retention issues, and compounds are more costly for pharmaceutical companies to develop. [xxv],[xxvi] We need the right funding to incentivise progress, but even treatments approved by NICE must be pushed for us to access. Clinicians are chasing local Clinical Commissioning Groups (CCGs) for approval – but we need the push to come from somewhere else.

Where next?

It’s clear that some big changes need to happen before we can claim parity of esteem in the UK. Diagnosing and treating depression sits with every clinician – but in order to do so, we need the right tools, up-to-date training and education. Only then can we provide the care that our patients desperately need.

References

[i] Mental Health First Aid (MHFA) England. (2020). Mental health statistics. Available at: https://mhfaengland.org/mhfa-centre/research-and-evaluation/mental-health-statistics/. Accessed: June 2020.

[ii] Harvard Health Publishing. Major Depression. Available at: https://www.health.harvard.edu/a_to_z/major-depression-a-to-z. Accessed: June 2020. 

[iii] Blumenthal JA, Babyak MA, Doraiswamy PM, et al. Exercise and Pharmacotherapy in the Treatment of Major Depressive Disorder. Psychosom Med. 2007;69(7):587–96.

[iv] The National Mental Health Development Unit (NMHDU). The Costs of Mental Ill Health. Available at: https://www.networks.nhs.uk/nhs-networks/regional-mental-health-workshop-mids-east/documents/supporting-materials/nmhdu-factfile-3.pdf.

[v] Henderson C, Evans-Lacko S, Thornicroft G. Mental Illness Stigma, Help Seeking, and Public Health Programs. Am J Public Health. 2013;103(5):777–78.

[vi] Gerber PD, Barrett JE, Barrett JE, et al. The Relationship of Presenting Physical Complaints to Depressive Symptoms in Primary Care Patients. J Gen Intern Med. 1992;7(2):170–3.

[vii] Kupferber A, Bicks L, Hasler G. Social functioning in major depressive disorder. Neurosci Biobehav Rev. 2016;69:313–332.

[viii] Barley EA, Murray J, Walters P, et al. Managing depression in primary care: A metasynthesis of qualitative and quantitative research from the UK to identify barriers and facilitators. BMC Family Practice. 2011;12:47.

[ix] Arroll B, Moir F, Kendrick T. Effective management of depression in primary care: a review of the literature. BJGP Open. 2017;1(2):bjgpopen17X101025.

[x] Ng CWM, How CH, Ng YP. Major depression in primary care: making the diagnosis. Singapore Med J. 2016;57(11):591–597.

[xi] Department of Health. (2014). Achieving Better Access to Mental Health Services by 2020. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/361648/mental-health-access.pdf. Accessed: June 2020.

[xii] NHS Oxfordshire CCG. (2017) Commissioning for Value Mental health and dementia pack. Available at: https://www.england.nhs.uk/wp-content/uploads/2017/07/cfv-oxfordshire-mhidp.pdf. Accessed: June 2020.

[xiii] Irving G, Neves AL, Dambha-Miller H, et al. International variations in primary care physician consultation time: a systematic review of 67 countries. BMJ Open. 2017;7:e017902.

[xiv] Pulse Today. What’s stopping GPs looking their patients in the eye? Available at: http://www.pulsetoday.co.uk/whats-stopping-gps-looking-their-patients-in-the-eye/11016268.article. Accessed: June 2020. 

[xv] MIND. (2016). GPs and practice nurses aren’t getting enough mental health training. Available at: https://www.mind.org.uk/news-campaigns/news/gps-and-practice-nurses-aren-t-getting-enough-mental-health-training/. Accessed: June 2020.

[xvi] American Psychiatric Association. (2013) Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Association.

[xvii] WHO. The ICD-10Classification of Mental and Behavioural Disorders Diagnostic criteria for research, https://www.who.int/classifications/icd/en/bluebook.pdf.

[xviii] Kraus C, Kadriu B, Lanzenberger R, et al. Prognosis and Improved Outcomes in Major Depression: A Review. Transl Psychiatry. 2019;9(1):127.

[xix] Herzog DP, Wagner S, Ruckes C, et al. Guideline adherence of antidepressant treatment in outpatients with major depressive disorder: a naturalistic study. Eur Arch Psychiatry Clin Neurosci. 2017;267(8):711–721.

[xx] National Institute for Clinical Excellence. (2009) Depression in adults: recognition and management. Available at: https://www.nice.org.uk/guidance/cg90. Accessed: June 2020.

[xxi] Hicks PB, Sevilimedu V, Johnson GR, et al. Predictability of Nonremitting Depression After First 2 Weeks of Antidepressant Treatment: A VAST-D Trial Report. PRCP. 2019: doi.org/10.1176/appi.prcp.20190003.

[xxii] NHS. Adult Improving Access to Psychological Therapies programme. Available at: https://www.england.nhs.uk/mental-health/adults/iapt/. Accessed: June 2020.

[xxiii] National Institute of Mental Health. (2019). Technology and the Future of Mental Health Treatment. Available at: https://www.nimh.nih.gov/health/topics/technology-and-the-future-of-mental-health-treatment/. Accessed: June 2020.

[xxiv] MQ. UK Mental Health Research Funding 2014–2017. Available at: https://s3.eu-central-1.amazonaws.com/www.joinmq.org/UK+Mental+Health+Research+Funding+2014-2017+digital.pdf

[xxv] Liu Y, Pencheon E, Hunter RM, et al. Recruitment and Retention Strategies in Mental Health Trials – A Systematic Review. PLoS One. 2018;13(8):e0203127.

[xxvi] Tufts Impact Report. 2012. Pace of CNS drug development and FDA approvals lags other drug classes.

Published online: 23/7/20