Treating to target in major depressive disorder: response to remission to functional recovery

Abstract

Treating to target in chronic diseases [e.g. Major Depressive Disorder (MDD)] fosters precision, consistency, and appropriateness of treatment selection and sequencing. Therapeutic target definitions/endpoints in MDD should satisfy patient-, provider-, and societal expectations. Functional recovery in depression and return to both physical and mental health are the overarching therapeutic objectives. Treating to target in MDD implies multidimensional symptomatic remission, with a particular emphasis on cognitive function and aspects of positive mental health. Several atypical antipsychotic agents (i.e. brexpiprazole, aripiprazole, quetiapine) are FDA-approved as augmentation agents in MDD. Vortioxetine, duloxetine, and psychostimulants have evidence of independent, direct, and robust effects on cognitive function in MDD. Vortioxetine is the only agent that demonstrates efficacy across multiple cognitive domains in MDD associated with functional recovery. Measurement-based care, health information technology/systems, and integrated care models (e.g. medical homes) provide requisite tools and health environments for optimal health outcomes in MDD. Achieving remission in MDD does not equate to health. Return to positive mental health as well as full functioning provide the impetus to pivot away from traditional provider-defined outcomes toward an inclusive perspective involving patient- and society-defined outcomes (i.e. optimization of human capital). As in other chronic diseases, treating to target (e.g. cognitive function) further increases the probability of achieving optimal health outcomes.

Remission and recovery associated with lurasidone in the treatment of major depressive disorder with subthreshold hypomanic symptoms (mixed features): post-hoc analysis of a randomized, placebo-controlled study with longer-term extension

“…While both symptomatic and functional improvement are important components of full recovery, 21,23,[35][36][37][38][39][40] and may be linked, as demonstrated in several studies, 23,[35][36][37][38] they are not necessarily always coincident. 21,23,[35][36][37][40][41][42][43] The observation that functional recovery often lags behind symptomatic or syndromal recovery 41 may account for this lack of coincidence in the components of recovery.…”

“…21,23,[35][36][37][40][41][42][43] The observation that functional recovery often lags behind symptomatic or syndromal recovery 41 may account for this lack of coincidence in the components of recovery. Findings from this analysis indicated that there was a moderately high level of concordance between symptomatic remission and functional remission at the endpoints of both the core (77.9%) and extension (65.9%) studies.…”

Assessing and measuring cognitive function in major depressive disorder

“…Understanding the importance of capturing varying domains/dimensions of cognitive function has a major role in improving MBC as functional outcomes can vary, dependent on impairment and/or improvement of varying domains/dimensions 9. An attribute of a screening/measurement tool for cognition in MDD is its ability to detect deficits across one or more of the domains known to be affected in MDD.…”

“…Measurement-based care (MBC) improves treatment outcomes in chronic medical disorders and provides opportunities to increase precision, consistency and appropriateness of care 9. As such, given the impact of MBC, the appropriateness and suitability of the tools used is important.…”

Impact of inequalities in health care on the mortality risk of individuals with severe mental illnesses

“…At a minimum, societal changes should inform how the issue of excess/premature mortality in SMI is framed, understood, and addressed, as advances in science and technology are apparently benefiting only the mentally healthy part of the population. 7 A commitment to first recognizing and then addressing the problem of excess/premature mortality in SMI is needed from all actors, from healthcare policy makers through healthcare providers to patient and peer advocacy groups.…”