Effects of Combined Pharmacotherapy

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EFFECTSOFCOMBINED

PHARMACOTHERAPYAND

PHYSICOTHERAPYFORIMPROVINGWORK

FUNCTIONINGINMAYORDEPRESIVEDISORDER.

Chandra kurniawan

Sindya wasundariJohan budiman

Kadek Sinthia

Yuddy Fiyanthi

Winda Dwiastuti

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I. BACKGROUND

Major depressive disorder is a leading cause of work-related disabilityand lost work productivity.

First-line recommended treatments for major depressive

disorder include antidepressants and cognitivebehavioural

therapy (CBT).

The research will combining telephone-delivered CBT with anantidepressant would improve symptom and work productivity outcomescompared with an antidepressant alone.

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II. AIMS

To examine symptom-based and work functioningoutcomes with combined pharmacotherapy andpsychotherapy treatment of major depressive disorder.

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III. METHOD

Employed patients with a DSM-IV diagnosis of major

depressive disorder were treated with escitalopram 1020mg/day for the entire 12 weeks and randomised to :

Outcomes included the MontgomeryAsberg DepressionRating Scale (MADRS), administered by masked evaluators

via telephone,and self-rated work functioning scales

completed online

telephone-administeredcognitivebehavioural

therapy (telephone CBT)

(n = 48)

adherence-remindertelephone calls (n = 51).

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A. PARTICIPANTS

Participant were recrited from clinic referrals and by

advertising at 3 side ( Vancouver, Calgary dan

Toronto).Inclusion Criteria Exclusion Criteria

and out-patients aged 19-

65 years olddiagnosis of major depressivedisorder by DSM-IV criteria

Current paid employment of 15h/week

MADRS score : 19 or higher

Competency to giveinformation

Off work on short- or long- ability

Pregnant of lactating Serious suicidal riskUnstable medical conditionsdiganose of OMD, substancemisuse/dependence.

Use of antidepresant or psychotropic drugs

within 7 days of baseline visit.Treatment-resistance in current episode.Previous use of escitalprolam or CBT fordepression.

Use any additional treatment for depressionduring study.

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B. OUTCOMEASSESSMENTS

Change in the MADRS score from baseline to end-point.

a. Response : if 50% improvement in MADRS scores to

end-point.b. Remission : if end-point MADRS 12

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C. PROCEDURES

Screening + Informed Consent

Make schedule for five study visits (baseline, 2, 4, 8 and 12 weeks) to patient.

Monitored medications and documend adverese event (by psychiatrists).

Rated the patient using the MADRS over the telephone by trained independentevaluators, and masked to treatment assignment and adverse event (by structureinterview guide) within 2 days of each study visit.

Give patient an email with a link tonansecure internet website to complete thestudy quistionares.

Number of Participant : 99 evaluable participant

End Participant : 86 participanteleminated because adverese

events

All comparison were analysed using ANCOVA.

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D. STUDYTREATMENTS

1. Medication

Escitalopram, dose starting with 10mg/ day and increasing to 20 mg/day.

2. CBT

Used a telephone-administrated CBT program (30-40 min instead of 60 min

per session). Eight telephone CBT session were schedule over 8-10 weeks.

Initial session occured within 2 weeks of randomisations Focused on

motivation enhancement excercises. Subsequent sessions occured weeklyFocused in identify, challenging

and distancing from negative thoughts.

Final sessions Focused on a personal care plan and self management

skills.

3. Control Condition

A 10-minute structured telephone call weekly, with enquiry about progress

and reminders to take medication properly.

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IV. RESULTS

a. Clinical OutcomeThere was no signif icant dif ference between the

telephone-CBT and escitalopram-alone groups, with

only small observed effect size (d=0.16).

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b. Work Function Outcome

The work functioning scale did show signi f icantdi f ferences between treatment conditionts. In the LOCFanalysis, the telephone-CBT group had a significantly greaterimprovement than the escitalopram-alone group (p=0.046).

Unfortunately, from baseline to end-point, the escitalopram-alone group had num erical ly higher reduc t ion in hours ofwork missed than the telephone-CBT group.

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V. DISCUSSION

The main results showed that adjunctive

telephoneadministered CBT in combination withescitalopram did not result in differences in

symptom-based clinical outcomes compared with

escitalopram alone; however, the combination

treatment did result in superior improvement insome aspects of work productivity, as assessed by

instruments designed to assess productivity

change.

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Telephone-administered psychotherapy has been

shown in meta-analyses to be more effective than

treatment-as-usual conditions in reducing symptoms

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CONTDISCUSSION

In this study, telephone CBT was well accepted by

patients, with 79% of participants rating themselves

as satisfied or highly satisfied with the therapy

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VI. LIMITATION

1. The sample size of this study may have limited

power to detect smaller effect sizes in clinical and

functional outcomes

2. Work functioning and productivity was measured

only with self-rating scales

3. the participants were not masked to treatment

condition and the control condition consisted of

adherence reminder telephone calls that were

more brief than the telephone CBT sessions, sowe cannot exclude the possibility that attention,

patient expectations or other non-specific factors

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4. The telephone-delivered CBT used in this study

was a brief (eight, 30-minute sessions)

intervention designed for use in primary care

settings

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CONCLUSION

Combinaed treatment with escitalopram and

telephone administered CBT significantly improved

some self-reported work functioning outcomes, but

not symptom-based outcomes, compared with

escitalopram alone.

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CRITICAL APPRAISAL

AN ARTICLE ON THERAPY19


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Documents

Effects of Combined Pharmacotherapy