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Treatment Resistant Depression Associated With High Disease Burden for Patients and Their Communities
Patients with treatment resistant depression (TRD) have a 23% higher chance of death, use twice as much outpatient care, and spend 3 times longer in inpatient care than other depressed patients, according to cohort study findings recently published in JAMA Psychiatry.
“The findings show that TRD was associated with higher disease burden with respect to health care resource utilization, lost workdays, intentional self-harm, and mortality and that these findings are not explained by [major depressive disorder (MDD)] duration,” said Johan Lundberg, MD, PhD, adjunct professor of psychiatry, Department of Clinical Neuroscience, head of the mood disorder section at the Northern Stockholm Psychiatry Clinic, and coauthors. “The long duration from MDD diagnosis until TRD suggests that clinicians could improve their alignment to recommendations of timely follow-up of patient symptoms.”
For this population-based observational study, the authors utilized data from the Stockholm MDD Cohort to identify cases of MDD between 2010 and 2017 that met the criteria for TRD (defined as having received 3 or more consecutive, unsuccessful antidepressant treatments). Main outcomes included psychiatric and nonpsychiatric comorbid conditions, antidepressant treatments, use of health care resources, workdays missed, all-cause mortality, deliberate self-harm, and instances of TRD.
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Researchers identified over 158,000 instances of MDD episodes, of which 12 793 (11%) fulfilled the criteria for TRD. The median (IQR) time from onset of MDD episode to TRD was 552 days (294-932). The most common class of antidepressant treatment across all steps was selective serotonin reuptake inhibitor (SSRI), and 5907 (46.2%) received psychotherapy before the initiation of the third pharmacological antidepressant intervention.
Compared to those experiencing MDD without TRD 12 months after the index date, patients with TRD episodes spent more time receiving inpatient treatment (mean, 3.9 days; 95% CI, 3.6-4.1, vs 1.3 days; 95% CI, 1.2-1.4) and missed more work days (mean, 132.3 days; 95% CI, 129.5-135.1, vs 58.7 days; 95% CI, 56.8-60.6).
For comorbid conditions experiences, patients experiencing TRD were more likely to experience anxiety, stress, sleep disorders, and substance use disorders. They were also 4 times more likely to intentionally self-harm. The all-cause mortality rate for patients with MDD experiencing TRD was 10.7/1000 person-years at risk, compared to 8.7/1000 person-years at risk for patients with MDD without TRD (hazard ratio, 1.23; 95% CI, 1.07-1.41).
Finally, researchers found that the most important prognostic factor for TRD was the severity of MDD at the time of diagnosis, measured using the Montgomery-Åsberg Depression Rating Scale (MADRS-S) (C index=0.69).
“We would benefit from identifying patients at risk of developing treatment resistant depression, since it causes a great deal of personal suffering and is a burden for the whole of society,” said Professor Lundberg.
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