December 17, 2009
Supplements and Featured Publications, Major Depressive Disorder and Functional Impairment: Key Concepts for Enhancing Patient Outcomes, Volume 15, Issue 11

Major depressive disorder (MD) is a prevalent illness associated with marked disability and substantial socioeconomic burden.1 With the advent in recent years of more effective, better tolerated pharmaceutical treatment options, the common use of depression-specific outcome measures to monitor symptomatic improvement, and more clearly defined treatment goals, there has been some improvement in the quality of care for patients with MD. However, the modest rates of successful treatment achieved in real-world clinical practice indicate that additional changes are necessary to further enhance the effectiveness of disease management.2

MD is often a chronic disorder, marked by periods of symptomatic remission and recurrences,3 whose course can be likened to that of adult asthma.4 Many patients with either condition have frequent, recurrent episodes marked by nearly asymptomatic periods when few overt symptoms are seen, whereas others may have chronic, subsyndromal symptoms that persist despite optimal treatment or because of poor treatment adherence.5 For each condition, clinicians must understand that to ameliorate functional impairment and/or prevent recurrences, maintaining an aggressive treatment approach for an extended or indefinite period may be necessary.

In the first 2 articles of this supplement, a description of the unique nature of the functional impairment associated with MD is provided, with special focus on the importance of achieving early, quality disease remission and the need for long-term maintenance therapy. An overview of the significant disability and increased healthcare costs seen in patients with MD is also presented. In the latter 2 articles, the positives and negatives of current disease rating scales that assess related domains beyond depressive symptomatology (eg, patient function) are reviewed, along with the benefits associated with the regular use of functional outcome measures to more broadly assess treatment effects in patients with MD. In addition, recent developments in the primary care-based health service models that have been shown to enhance detection and quality of care that depressed patients receive are described. Finally, an expanded definition of depressive remission, which includes criteria for depressive symptomatology, level of real-world functioning, and quality of life, is proposed, and key characteristics of assessment tools capable of adequately capturing necessary information in relevant domains is explored.

1. Hirschfeld RM, Montgomery SA, Keller MB, et al. Social functioning in depression: a review. J Clin Psychiatry. 2000;61(4):268-275.

2. Masand PS. Tolerability and adherence issues in antidepressant therapy. Clin Ther. 2003;25(8):2289-2304.

3. Simon GE. Long-term prognosis of depression in primary care. Bull World Health Organ. 2000;78(4):439-445.

4. Klinkman MS, Schwenk TL, Coyne JC. Depression in primary care-more like asthma than appendicitis: the Michigan Depression Project. Can J Psychiatry. 1997;42(9):966-973.

5. Katon W, Unützer J, Russo J. Major depression: the importance of clinical characteristics and treatment response to prognosis. Depress Anxiety. 2009 Oct 1. [Epub ahead of print] doi:10.1002/da.20613.