01.09.2014 Treatment of depression in Finland – why and how? Erkki Isometsä, Dr.Med.Sci., Professor of Psychiatry, Department of Psychiatry, University of Helsinki; Chief physician (part-time), Department of Psychiatry, Helsinki University Central Hospital (HUCH); Research Professor (part-time) , National Institute for Health and Welfare, Helsinki www.helsinki.fi/yliopisto Potential conflict of finterest disclosure: September 2011 – September 2014 • Employment by a pharmaceutical company: (Never) • Research funding from a pharmaceutical company: (Never) • Advisory Board or Speakers Bureau Membership: (Never) • Honoraria for lecturing in educational meetings sponsored by a pharmaceutical company o Servier x 2 (2012) • Honaria for lecturing, other o Finnish Medical Society Duodecim (2012) o Finnish Medical Association (2014) o European College of Neuropsychopharmacology, ECNP (2012) o Royal College of Psychiatrists (2012) o Columbia University (2013) • Funding for participation in scientific meetings from pharmaceutical companies o Lundbeck x 1 (2012) • Licensed psychotherapist (Valvira) o Income since 1989 1/273 inhabitants in 2013 medicalization ≠ pharmacotherapy Why should depression be treated? Depression and associated disability in Finland in 2012 • Increase in disability pensions ended 2007. • No. of sick leave periods 26 709 (no. part- time sick leaves 1980). • New disability pensions granted due to depression for 3 549 individuals. • Total no. of disability pensions for depression in Finland 36 358. Honkonen T & Gould R. SLL 44/2011 • Total costs involved > 600 million €. Cumulative risk of completed suicide among subjects in psychiatric care in Denmark Cumulative incidence, register-based follow-up to 36y. (median 18y.) since first treatment contact males females Nordentoft M et al., Arch Gen Psychiatry 2011;68:1058-1064. Treatment: The Finnish Current Care Guidelines Annual prevalence of depressive syndromes in the general population <1% 4-5% Psychotic depression Depressive episodes and recurrent depression Dg F32-33 10-15% mild depressive symptoms Phases of treatment Current Care Guidelines, 2009 6 mo. relapse Acute treatment Continuation phase Recurrent depression (F33) recurrence Maintenance phase Acute treatment of depression Current Care Guidelines, 2009 Treatment modality Mild Moderate Severe Psychotic Psychotherapies + + (+) - Antidepressants + + + + Antipsychotics - - - + Electroconvulsive therapy (ECT) - - + + Psychotherapeutic treatment Central forms of psychotherapy in different treament phases Current Care Guidelines, 2009 Treatment modality Duration and intensity Evidence in phases of treatment Acute Continuation and maintenance Chronic and/or complicated A - - Brief MBCT (8-16x, 1x/wk) - A - Brief/medium-term CBASP (12-40x) - - B Long-term (40-160x, 1-2x/wk) D D C Interpersonal (IPT) Brief (12-16x, 1 x/wk) A A - Psychodynamic Brief (16-25x, 1x/wk) B - - Long-term (80-240x, 1-3x/wk) B D B Cognitive / Cognitive-behavioural (CBT) MBCT = mindfulness-based cognitive therapy; CBASP = cognitive behavioral analysis system of psychotherapy Effectiveness of psychotherapy in depression? • In the Helsinki Psychotherapy Study (HPS, N=326), patients depression/and or anxiety improved significantly on both brief and longterm psychodynamic as well as solution-focused therapies, but brief therapies were estimated not to be sufficient treatment in the majority of patients. • In a study (N=341) comparing cognitive-behavioral vs. psychodynamic brief therapies (16 sessions in 22 wks) in outpatients psychiatric care in Amsterdam, proportion of patients remitted 23% in both groups, responders 39% and 37% (Driessen E et al., Am J Psychiatry 2013;170:1041-50.) • In the UK Improved Access to Psychological Therapies (IAPT) Project, a report of 7859 pts found 55% of patients improved after treatment. However, attrition rate was 47% (Richards & Borglin, J Affect Disord 2011;133:51-60). Psychotherapy: the issue of capacity • Overall 5475 licensed psychotherapist aged ≤ 65 y in 31.12.2013 (Valvira). • In 2009-13, no. of registered new therapists varied annually between 275-432. • Of Finnish psychotherapists in 2011, o ¼ were not currently providing psychotherapy o 85% provided individual therapy o Median time devoted to psychotherapeutic work 15h/wk o Estimated no. of patients treated per year 18 pts./therapist o Regional distribution uneven, 3-fold differences in density Rough estimate: 40 -70 000 patients treated/year, in therapies of 1-3 y Valkonen J et al. Psykoterapeutit Suomessa. Psykoterapiapalvelut ja niiden järjestäminen. KELA, 2011 Pharmacotherapy Sales of antidepressant drugs in Finland in 1990-2012 • Altogether 444 184 individuals in 2012. • DDD 69,81 (DDD 70,24 in 2011) • Change from the year 2011: -1%. • Likely causes of increase: • Increased treatment-seeking and provision for depression, particularly in primary health care Finnish Statistics on Medicines, 2012 • New treatment indications • Continuation/maintenance treatment Sales of antidepressant drugs in Finland in 1990-2012 • Altogether 444 184 individuals in 2012. • DDD 69,81 (DDD 70,24 in 2011) • Change from the year 2011: -1%. • Likely causes of increase: • Increased treatment-seeking and provision for depression, particularly in primary health care Finnish Statistics on Medicines, 2012 Current Care Guidelines • New treatment indications • Continuation/maintenance treatment Sales of antidepressants in the Nordic countries in 2005-2012 From: Health Statistics for the Nordic Countries; Nomesko, 2013 Typical 6-8 wk antidepressant trial response rates 60% 50% 40% 30% 20% 10% 0% Spontaneous remission Placebo Antidepressant Typical 6-8 wk antidepressant trial response rates 60% 50% 40% 30% 20% 10% 0% Spontaneous remission Placebo Antidepressant The THREAD Study (N=220) : Effectiveness of SSRI-treatment added to supportive treatment in UK primary care Remission by 12 wks: 42% vs. 24%, NNT = 6 (95% l.v. 4-26) Kendrick T et al. Health Technology Assessment 2009;13:22. DOI:10.3310/htaI 3220 Phases of treatment Current Care Guidelines, 2009 6 mo. relapse Recurrent depression (F33) recurrence NNT 3-6 Acute treatment Continuation phase Maintenance phase Conclusions • Depression is associated with remarkable disability, significant excess mortality, and markedly elevated suicide mortality. • In mild to moderate depression, there are no significant differences in efficacy or effectiveness between psychotherapies or antidepressants. • In severe or psychotic depression pharmacotherapy or other biological treatment is usually needed. • Combined and integrated treatments are needed and most effective.