Exploration of disease variables (DV) in the management of treatment-resistant depression (TRD) in older adults: Results of a Continuous Quality Improvement (CQI) Project
A. S. LuthraIntroduction
TRD is defined as inadequate response to two adequate (optimal and duration) trials of two different classes of antidepressants. Literature identifies co-morbid psychiatric illnesses , personality factors , medical illnesses and patient factors contributory to TRD. Phenotypic manifestations of each subsequent episode of clinical depression changes over its lifetime of expression and so does the propensity to recurrences. They are referred to as index episodes specifiers (IES) and longitudinal course specifiers (LCS), respectively. Changes in index episodes and longitudinal course are due to the phenomenon of episode sensitization and kindling, respectively . Diurnal variation (DiV) is another disease variable established in the literature. I have labelled IEC, LCS and DiV as DV .
Objectives
I hypothesize that identification, and treatment of the DV is the key to increasing the probability of response in established TRD in older adults. The principles governing the project design were derived from the observational case study design under the evaluative framework of the Continuous Quality Improvement governance structure. Results of CQI project on a Program for Older Adults (POA), a tertiary mood disorders program at Homewood Health, Guelph, Ontario, are presented to support this a priori hypothesis
Methods
A random sample of patients admitted to POA were included in the project. Each patient was routinely evaluated with Geriatric Depression Scale (GDS)] and Becks Depressions Inventory (BDI), on admission and at discharge. DSM-IV-R pictogram was used to establish LCS. Each patient was evaluated two to three times a week to establish IES and DiV. Formulated DV were used t0 design pharmacological intervention each week. Each patient also engaged in evidence informed psychotherapies.
Results
100 patients ( 70 females: 29 males) were evaluated. The average admission score of the patients on GDS was 20.99 and upon discharge was 6.25 (p<0.00000000000000000000000000000000000000517). The average admission score of the patients on BDI was 26.32 and upon discharge was 6.21 (p<0.00000000000000000000000000000000203). 93 of the 100 patients had complete remission on GDS and 92 of the 100 had complete remission on BDI. 7 of the 100 patients showed partial response on GDS and 7 of the 100 patients showed partial response on BDI. 0 of the 100 patients showed no response on GDS and 1 of 100 patients showed no response on BDI.
Conclusions
Over 90% of the established TRD in older adults responded to the individually tailored pharmacological interventions targeting the DV, while concurrently receiving evidenced informed psychotherapies. These results justify the generation of a priori hypothesis for the need for identification, and treatment of DV prior to labelling older adults as TRD.
Disclosure of Interest
None Declared