Helping Patients With Depression Achieve Wellness
Mark Hyman Rapaport, MD
Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center, and the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles
Raising the Bar for Treatment Outcomes in Depression
For many years, response has been the goal for the treatment of depression and has been defined as a 50% or greater reduction on an objective measure of improvement such as the HAM-D or “much improved” or “very much improved” ratings on the CGI-I. However, between 1995 and 2006, researchers1–3 found that residual depressive symptoms were associated with early relapse and more recurrences than an asymptomatic state, so the next optimal treatment outcome became remission (AV 1). The exact definition of remission is debatable. Some have defined remission as a score of ≤ 7 on the HAM-D-17 or a score of ≤ 5 on the QIDS; Judd et al1 described remission as the complete resolution of all signs and symptoms of depression, which is a more rigorous definition. Recently, researchers4 have discussed going beyond remission to achieve wellness. The concept of wellness involves not only the complete elimination of signs and symptoms of a depressive disorder but also the full restoration of premorbid levels of functioning and quality of life (eg, social interactions, personal relationships, work functioning, and a sense of depth and richness in life). Patients who achieve wellness may have an increased probability of staying well.
Importance of Using Objective Measures in Clinical Practice
Although rating scales have been used in research and in definitions of response and remission, psychiatry and psychology practitioners are often reluctant to use quantifiable measures to assess whether treatments are benefiting patients (AV 2).5 This reluctance may be attributed to a commonly held concern in the fields of psychiatry and psychology about appearing to be biased or judgmental, thus adversely impacting therapy. A recent survey5 of US psychiatrists asked why standardized scales are not used to measure depression treatment outcomes. The 3 most common answers were: (1) that they were not trained to use them, (2) that scales would take too much time, and (3) that they did not believe that using scales would be clinically helpful.
In actuality, failing to measure outcomes may lead to lower quality of care and give the patient the sense that the clinician is not engaged in the treatment process. Conversely, implementing measure-based care may facilitate patients becoming more actively involved in the treatment process, because this allows both patients and clinicians to measure improvement over time. Working with patients to track outcomes of interventions engages them in therapy and enhances the feeling that the clinician is concerned with symptom improvement and overall wellness. In addition, patients experience a sense of control over the treatment process, increasing the likelihood of adherence to therapy and thus achieving remission and wellness.
Tools to Objectively Measure Treatment Outcomes
Incorporating standardized objective measures into clinical practice is feasible and will improve assessment of treatment outcomes.6 Various tools are available to help clinicians determine the symptomatic and functional condition of patients (AV 3). The QIDS-SR,7 a brief patient-rated measure, has been validated by research.8 Also, the CGI9 can be conveniently used in the busy clinical setting. The SDS,10 a set of 3 Likert scales that may be either clinician- or patient-rated, and the WSAS,11,12 a self-rated measure using Likert scales, are practical tools. The 2 most commonly accepted measures of quality of life are the Q-LES-Q–SF13 and the MOS surveys.14–16
At Cedars-Sinai, we employ a novel method to examine well-being—we call this “the most troubling problem approach to care.” Specifically, patients are asked to identify the 3 most troubling problems in their lives (eg, symptoms, issues involving quality of life, and issues involving work functioning) and to quantify how troubling these problems are on a daily basis using a 1 to 10 Likert scale. With this approach, patients can assess the effectiveness of therapy on relevant personal concerns while progressing to wellness on a daily basis.
The ideal treatment outcome for patients with depression is wellness. To achieve this goal, clinicians must establish a collaborative approach to care with their patients, educating them as well as setting goals and outcomes for all phases of therapy. The frequency and content of visits should be tailored to meet the changing needs of patients over the course of acute, continuation, and maintenance therapy. More intense therapy may be needed from time to time, even during the maintenance phase. Implementing objective measures to assess improvement will help clinicians to choose appropriate interventions throughout treatment that will facilitate wellness.
CGI-I = Clinical Global Impressions-Improvement scale, CGI-S = Clinical Global Impressions-Severity scale, HAM-D-17 = 17-item Hamilton Rating Scale for Depression, MOS = Medical Outcomes Study, QIDS = Quick Inventory of Depressive Symptomatology, QIDS-SR = Quick Inventory of Depressive Symptomatology–Self Report, Q-LES-Q–SF = Quality of Life Enjoyment and Satisfaction Questionnaire Short Form, SDS = Sheehan Disability Scale, WSAS = Work and Social Adjustment Scale
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- Judd LL, Paulus MJ, Schettler PJ, et al. Does incomplete recovery from first lifetime major depressive episode herald a chronic course of illness? Am J Psychiatry. 2000;157(9):1501–1504.
- Paykel ES, Ramana R, Cooper Z, et al. Residual symptoms after partial remission: an important outcome in depression. Psychol Med. 1995;25(6):1171–1180.
- Rush AJ, Trivedi JH, Wisniewski SR, 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.
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- Trivedi MH, Rush AJ, Gaynes BN, et al. Maximizing the adequacy of medication treatment in controlled trials and clinical practice: STAR*D measurement-based care. Neuropsychopharmacology. 2007;32(12):2479–2489.
- Rush AJ, Trivedi MH, Ibrahim HM, et al. The 16-item Quick Inventory of Depressive Symptomatology (QIDS), Clinician Rating (QIDS-C), and Self-Report (QIDS-SR): a psychometric evaluation in patients with chronic major depression. Biol Psychiatry. 2003;54(5):573–583.
- Trivedi MH, Rush AJ, Ibrahim HM, et al. The Inventory of Depressive Symptomatology, Clinician Rating (IDS-C) and Self-Report (IDS-SR), and the Quick Inventory of Depressive Symptomatology, Clinician Rating (QIDS-C) and Self-Report (QIDS-SR) in public sector patients with mood disorders: a psychometric evaluation. Psychol Med. 2004;34(1):73–82.
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