Elsevier

Journal of Affective Disorders

Volume 174, 15 March 2015, Pages 390-396
Journal of Affective Disorders

Research report
What is important in being cured from depression? Discordance between physicians and patients (1)

https://doi.org/10.1016/j.jad.2014.12.004Get rights and content

Abstract

Aims

The comparison of what physicians and patients consider important in being cured from depression.

Methods

426 outpatients (in primary care and in psychiatric care) with a clinical diagnosis of major depression were included: at the start of antidepressant treatment, the importance of a range of items for being cured from depression (depressive, anxious and somatic symptoms, positive affect, functional impairment, quality of life) was assessed in physicians and patients separately and a ranking was made; after 3 months of treatment, the importance of these items for being cured from depression was re-assessed in the patients.

Results

The items ranked top 10 by physicians mainly contain depressive symptoms while those ranked top 10 by patients mainly contain positive affect items and this attention to positive affect even increases at 3 months follow-up and is higher in patients with recurrent depression than in patients with a first episode of depression. Somatic symptoms consistently get the lowest ranking, as well in physicians as in patients.

Conclusions

Physicians differ significantly from patients in what they consider important forbeing cured from depression’: physicians mainly focus on alleviation of depressive symptoms while patients mainly focus on the restoration of positive affect.

Introduction

Changes in symptom severity during antidepressant treatment are usually assessed with observer rating scales: the 17-item Hamilton Depression Rating Scale (HDRS) or the 10-item Montgomery–Asberg Depression Rating Scale (MADRS), hence giving priority to the physician׳s view on change (Hamilton, 1960, Montgomery and Asberg, 1979). The purpose of the HDRS was developing a scale for assessing severity and change during treatment within a population of patients already diagnosed with depression. It is interesting that the purpose of the MADRS was sensitivity and accuracy of change during antidepressant treatment: the authors chose the 10 items (out of the 65 items of the CPRS – Comprehensive Psychiatric Rating Scale) that changed most during treatment with a variety of antidepressants with different mechanisms of action (mianserin, amitriptyline, maprotiline and clomipramine) (Montgomery and Asberg, 1979, Asberg et al., 1978). For the assessment of the efficacy of antidepressants, regulatory bodies consistently request one of these 2 standard observer-rating depression scales to be used and physicians are trained to use them in clinical practice. It is important to mention that both scales were published even before DSM-III was introduced and the content of these scales hence does not fully represent the currently used diagnostic criteria for depression (American Psychiatric Association, 1980).

It is remarkable that the 2 core symptoms of the DSM diagnostic criteria are to a different degree included in the rating scales, but both symptoms do lose the ‘core symptom’ position they have in the diagnostic criteria. While sad or depressed mood is well represented in both scales, it is remarkable and/or problematic that anhedonia has a very marginal position in both scales.

The 17-item HDRS indeed pays more attention to negative affect items than to anhedonia: depressed mood (sadness, hopeless, helpless, worthlessness…hence not only referring to affect but also to cognitions), psychic anxiety (psychological: subjective tension and irritability, worrying) and somatic anxiety (Hamilton, 1960). Only one item is referring more or less to anhedonia: work and activities (thoughts and feelings of incapacity, fatigue or weakness, loss of interest in activities, hobbies or work, decrease in actual time spend in activities or decrease in productivity, stopping working…hence not only referring to anhedonia but also to functioning).

The same is true for the 10-item MADRS containing 3 negative affect items: apparent sadness (representing despondency, gloom and despair, (more than just ordinary transient low spirits), reported sadness (representing depressed mood, low spirits, despondency or feeling of being beyond help without hope) and inner tension (representing feelings of ill-defined discomfort, edginess, inner turmoil mounting to either panic, dread or anguish) (Montgomery and Asberg, 1979). And only one item is referring to anhedonia although in the higher scores it is referring to complete inability to feel positive as well as negative emotion: inability to feel (representing the subjective experience of reduced interest in the surrounding, or activities that normally give pleasure up to the experience of being emotionally paralyzed, inable to feel anger, grief or pleasure).

Two remaining questions are whether observer-rating indeed are superior to self-rating scales and whether the content of these observer rating scales really reflect the concerns of patients about outcome in depression treatment. It is known that discrepancies can exist between observer- and self-rating scales: in comparison to observer rating very severely depressed patients have been shown to underrate the severity of their depression while mildly depressed patients have been shown to overrate the severity of their depression (Möller, 2000). Discrepancies also exist between the content of the most frequently used rating scales and what patients expect from treatment: Zimmerman showed that, from a patient perspective, the rank order of the most important expectations from antidepressant treatment are first presence of positive mental health (optimism, vigor, self-confidence), second feeling like your usual, normal self, third return to usual level of functioning at work, home or school, fourth feeling in emotional control, fifth participating in and enjoying relationships with family and friends, and only sixth absence of symptoms of depression (negative affect) (Zimmerman et al., 2013). They developed the Remission from Depression Questionnaire (RDC), a 41-item self-report measure that assesses an array of features reported by patients as relevant to determining remission from depression, including positive mood (Zimmerman et al., 2013). Significant differences were found for HDRS remitted patients (observer rated) and RDQ remitted patients (self-rated) and depressed patients were shown to have a perspective of remission going beyond symptoms resolution and also including positive mental health or life satisfaction. On the same lines, another group developed the REMIT (Remission Evaluation and Mood Inventory Tool) questionnaire taking into account patient expectations: in predicting patient assessed recovery from depression, adding the 5 items of the scale (emotional control, contentedness, future seeming dark, ability to bounce back and happiness) to the Patient Health Questionnaire (PHQ, reflecting DSM criteria of depression) yielded an 11% increase in R2 beyond the 60% yielded by the PHQ (Nease et al., 2011). This picture seems to be far different from what regulatory bodies or physicians expect from outcome and from what the HDRS or MADRS assess and suggests that a broader perspective should be considered when assessing outcome. Moreover, real life patients often have comorbid anxious and somatic symptoms, have excessive negative affect and lack of positive affect, present with functional impairment in their occupational, social and family life and report a low quality of life (Demyttenaere et al., 2010, Demyttenaere et al., 2009, Watson et al., 1988a, Watson et al., 1988b, De Fruyt and Demyttenaere, 2009). The two standard scales show some differences here: the HDRS covers a somewhat broader spectrum of symptoms including anxiety and neurovegetative (somatic) symptoms while the MADRS is more focused on the depressive symptomatology but neither scale covers the whole range of issues/symptoms mentioned above.

Therefore, a more comprehensive assessment of change is probably warranted and the present study investigates the concordance or divergence between what physicians and patients consider to be the most important issues in considering cure from depression.

Section snippets

Ethics statement

This research was performed according to the principlesù of the Declaration of Helsinki, and written informed consent was obtained from the participants after explanation of the nature of the study. The study was approved by the ethics committee of Hôpital Universitaire Saint-Luc in Woluwe (Brussels).

Patient recruitment

This is a prospective, non-interventional study conducted in Belgium between February 2010 and July 2011 in both general and specialized (psychiatric) practices. According to the study protocol,

Diagnostic and clinical characteristics of the study population

Physicians had been asked to include patients with a diagnosis of clinical depression ‘where treatment with an antidepressant was indicated and initiated’. Based on the PHQ-depression scale scores, 69.8% fulfilled criteria for major depression. The mean scores on the different scales are given in Table 1.

Based on the HADS-anxiety scale 71.1% were probable cases and 20.0% were doubtful cases for an anxiety disorder. Overall, 16.0% of the patients did not fulfill screening/diagnostic criteria for

Discussion

Physicians were asked to enroll patients with major depressive disorder: only 69.8% of the included patients reached the threshold for ‘probable depression’ on the HADS depression subscale while 71.1% reached the threshold for ‘probable anxiety disorder’ on the HADS anxiety subscale. While 16% of the patients even did not reach the threshold neither for ‘probable depression’ nor for ‘probable anxiety disorder’, 57.1% of the patients reached the threshold for both ‘probable depression’ and

Role of funding source

Lundbeck Belgium provided the logistical support provided for performing this study; there was complete independence of researchers in the collection, analysis, and interpretation of the data and in the writing of the report, and in the decision to submit the paper for publication.

Conflict of interest

All authors have completed the Unified Competing Interest form.

Acknowledgment

All authors participated in conceiving and designing the study. Anne-Françoise Donneau and Adelin Albert analyzed the data and Koen Demyttenaere coordinated the writing of the manuscript. All authors have completed the Unified Competing Interest form and declare that (1) A-F. D. and A.A. had financial support from Lundbeck Belgium for the statistical analysis, (2) there are no relationships that might have an interest in the submitted work in the previous 3 years, (3) their spouses, partners,

References (26)

  • K. Demyttenaere et al.

    Caseness for depression and anxiety in a depressed outpatient population: symptomatic outcome as a function of baseline diagnostic categories

    Prim. Care Companion J. Clin. Psychiatry

    (2009)
  • K. Demyttenaere et al.

    Do general practitioners and psychiatrists agree about defining cure from depression. The DEsCRIBETM survey

    BMC Psychiatry

    (2011)
  • Cited by (0)

    View full text