Algorithms For Treatment of Major Depressive Disorder: Efficacy and Cost-Effectiveness

Abstract

In spite of multiple new treatment options, chronic and treatment refractory courses still are a major challenge in the treatment of depression. Providing algorithm-guided antidepressant treatments is considered an important strategy to optimize treatment delivery and avoid or overcome treatment-resistant courses of major depressive disorder (MDD). The clinical benefits of algorithms in the treatment of inpatients with MDD have been investigated in large-scale, randomized controlled trials. Results showed that a stepwise treatment regimen (algorithm) with critical decision points at the end of each treatment step based on standardized and systematic measurements of response and an algorithm-guided decision-making process increases the chances of achieving remission and optimizes prescription behaviors for antidepressants. In conclusion, research in MDD revealed that systematic and structured treatment procedures, the diligent assessment of response at critical decision points, and timely dose and treatment type adjustments make the substantial difference in treatment outcomes between algorithm-guided treatment and treatment as usual.

Key words

treatment algorithm - outcome - treatment as usual - medical decision-making

• References

• 1 Ferrari AJ, Charlson FJ, Norman RE. Burden of depressive disorders by country, sex, age, and year: findings from the global burden of disease study 2010. PLoS Med 2013; 10: e1001547
• 2 Murray CJ, Vos T, Lozano R. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2013; 380: 2197-2223
• 3 Angst J, Merikangas K. The depressive spectrum: diagnostic classification and course. J Affect Disord 1997; 45: 31-39
• 4 Kendler KS, Thornton LM, Gardner CO. Stressful life events and previous episodes in the etiology of major depression in women: an evaluation of the “kindling” hypothesis. Am J Psychiatry 2000; 157: 1243-1251
• 5 Rush AJ. STAR*D: what have we learned?. Am J Psychiatry 2007; 164: 201-204
• 6 Rush AJ. Practice guidelines and algorithms. In: Weissman MM. ed. Treatment of Depression. Bridging the 21st Century. Washington, DC: Am Psychiatric Press, Inc; 2001: 213-240
• 7 Adli M, Rush AJ, Moller HJ. et al. Algorithms for optimizing the treatment of depression: making the right decision at the right time. Pharmacopsychiatry 2003; 36 (Suppl. 03) 222-229
• 8 Adli M, Bauer M, Rush AJ. Algorithms and collaborative-care systems for depression: are they effective and why? A systematic review. Biol Psychiat 2006; 59: 1029-1038
• 9 Bauer M, Severus E, Möller HJ. et al. Pharmacological treatment of unipolar depressive disorders: summary of WFSBP guidelines. Int J Psychiatry Clin Pract 2017; 3: 1-11
• 10 American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder (revision). Am J Psychiatry 2000; 157 04 1-45
• 11 American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder. 3rd edition American Psychiatric Association Publishing; 2010
• 12 Cleare A, Pariante CM, Young AH. et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol 2015; 29: 459-525
• 13 Bauer M, Pfennig A, Severus E. et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders, part 1: update 2013 on the acute and continuation treatment of unipolar depressive disorders. World J Biol Psychiatry 2013; 14: 334-385
• 14 Rush AJ, Rago WV, Crismon ML. et al. Medication treatment for the severely and persistently mentally ill: the Texas Medication Algorithm Project. J Clin Psychiatry 1999; 60: 284-291
• 15 Rush AJ, Crismon ML, Kashner TM. et al. Texas Medication Algorithm Project, phase 3 (TMAP-3): rationale and study design. J Clin Psychiatry 2003; 64: 357-369
• 16 Crismon ML, Trivedi M, Pigott TA. et al. The Texas Medication Algorithm Project: report of the Texas Consensus Conference Panel on Medication Treatment of Major Depressive Disorder. J Clin Psychiatry 1999; 60: 142-156
• 17 Trivedi MH, Rush AJ, Crismon ML. et al. Clinical results for patients with major depressive disorder in the Texas Medication Algorithm Project. Arch Gen Psychiatry 2004; 61: 669-680
• 18 Toprac MG, Rush AJ, Conner TM. et al. The Texas Medication Algorithm Project Patient and Family Education Program: a consumer-guided initiative. J Clin Psychiatry 2000; 61: 477-486
• 19 Rush AJ, Gullion CM, Basco MR. et al. The Inventory of Depressive Symptomatology (IDS): psychometric properties. Psychol Med 1996; 26: 477-486
• 20 Rush AJ, Carmody T, Reimitz PE. The Inventory of Depressive Symptomatology (IDS): clinician (IDS-C) and self-report (IDS-SR) ratings of depressive symptoms. Int J Methods Psychiatr Res 2000; 9: 45-59
• 21 Trivedi MH, Rush AJ, Ibrahim HM. et al. The Inventory of Depressive Symptomatology, Clinician Rating (IDS-C) and Self-Report (IDS-SR), and the Quick Inventory of Depressive Symptomatology, Clinician Rating (QIDS-C) and Self-Report (QIDS-SR) in public sector patients with mood disorders: a psychometric evaluation. Psychol Med 2004; 34: 73-82
• 22 Fava M, Rush AJ, Trivedi MH. et al. Background and rationale for the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. Psychiatr Clin North Am 2003; 2: 457-494
• 23 Rush AJ, Fava M, Wisniewski SR. et al. Sequenced Treatment Alternatives to Relieve Depression (STAR*D): rationale and design. Control Clin Trials 2004; 25: 119-142
• 24 Lavori PW, Rush AJ, Wisniewski SR. et al. Strengthening clinical effectiveness trials: equipoise-stratified randomization. Biol Psychiatry 2001; 50: 792-801
• 25 Rush AJ, Trivedi MH, Wisniewski SR. et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry 2006; 163: 1905-1917
• 26 Rush AJ, Trivedi MH, Wisniewski SR. et al. Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression. N Engl J Med 2006; 354: 1231-1242
• 27 Trivedi MH, Fava M, Wisniewski SR. et al. Medication augmentation after the failure of SSRIs for depression. N Engl J Med 2006; 354: 1243-1252
• 28 Adli M, Berghöfer A, Linden M. et al. Effectiveness and feasibility of a standardized stepwise drug treatment regimen algorithm for inpatients with depressive disorders: results of a 2-year observational algorithm study. J Clin Psychiatry 2002; 63: 782-790
• 29 Bauer M, Pfennig A, Linden M. et al. Efficacy of an algorithm-guided treatment compared to treatment as usual: a randomized controlled study of inpatients with depression. J Clin Psychopharm 2009; 29: 327-333
• 30 Adli M, Wiethoff K, Baghai TC. et al. How effective is algorithm-guided treatment for depressed inpatients? Results from the randomized controlled multicenter German Algorithm Project 3 trial. Int J Neuropsychopharmacol 2017; 20: 721-730
• 31 Linden M, Helmchen H, Mackert A. et al. Structure and feasibility of a standardized stepwise drug treatment regimen (SSTR) for depressed inpatients. Pharmacopsychiatry 1994; 27 (Suppl. 01) 51-53
• 32 Bech P, Rafaelsen OJ. The melancholia scale: development, consistency, validity and utility. In: Sartorius N, Ban TA. (eds.) Assessment of Depression. Berlin, Heidelberg: Springer; 1986: 259-269
• 33 Wiethoff K, Bauer M, Baghai TC. et al. Prevalence and treatment outcome in anxious versus nonanxious depression: results from the German Algorithm Project. J Clin Psychiat 2010; 71: 1047-1054
• 34 Bloom DE, Cafiero ET, Jané-Llopis E. The global economic burden of noncommunicable diseases. Geneva: World Economic Forum; 2011
• 35 Friemel S, Bernert S, Angermeyer MC. et al. Die direkten Kosten von depressiven Erkrankungen in Deutschland. Ergebnisse aus dem European Study of Epidemiology of Mental Disorders (ESEMeD) Projekt. Psychiatr Prax 2005; 32: 113-121
• 36 Ricken R, Wiethoff K, Reinhold T. et al. Algorithm-guided treatment of depression reduces treatment costs – results from the randomized controlled German Algorithm Project (GAPII). J Affect Disord 2011; 134: 249-256
• 37 Ricken R, Wiethoff K, Reinhold T. et al. A standardized stepwise drug treatment algorithm for depression reduces treatment costs – results from the German Algorithm Project (GAP3). J Affect Disord 2018; 228: 173-177
• 38 Guo T, Xiang YT, Xiao L. et al. Measurement-based care versus standard care for major depression: a randomized controlled trial with blind raters. Am J Psychiatry 2015; 172: 1004-1013
• 39 Katon W, Russo J, Frank E. et al. Predictors of nonresponse to treatment in primary care patients with dysthymia. Gen Hosp Psychiatry 2002; 24: 20-27
• 40 Fava M, Uebelacker LA, Alpert JE. et al. Major depressive subtypes and treatment response. Biol Psychiatry 1997; 42: 568-576
• 41 Ezquiaga E, Garcia A, Pallares T. et al. Psychosocial predictors of outcome in major depression: a prospective 12-month study. J Affect Disord 1999; 52: 209-216
• 42 Viinamaki H, Hintikka J, Tanskanen A. et al. Partial remission in major depression: a two-phase; 12-month prospective study. Nord J Psychiatry 2002; 56: 33-33
• 43 Iosifescu DV, Nierenberg AA, Alpert JE. et al. The impact of medical comorbidity on acute treatment in major depressive disorder. Am J Psychiatry 2003; 160: 2122-2127
• 44 Keitner GI, Ryan CE, Miller IW. et al. 12-month outcome of patients with major depression and comorbid psychiatric or medical illness (compound depression). Am J Psychiatry 1991; 148: 345-350
• 45 Keitner GI, Ryan CE, Miller IW. et al. Recovery and major depression: factors associated with twelve-month outcome. Am J Psychiatry 1992; 149: 93-99
• 46 Keller MB, Gelenberg AJ, Hirschfeld RM. et al. The treatment of chronic depression, part 2: a double-blind, randomized trial of sertraline and imipramine. J Clin Psychiatry 1998; 59: 598-607
• 47 Keller MB, McCullough JP, Klein DN. et al. A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. N Engl J Med 2000; 342: 1462-1470
• 48 Rush AJ. Isn’t it about time to employ measurement-based care in practice?. Am J Psychiatry 2015; 172: 934-936