Multimodal approach is needed for effective treatment of depression with drugs which are safe, effective and well tolerated-Prof. Bernhard Baune


 Multimodal approach is needed for effective
treatment of depression with drugs which are safe,
effective and well tolerated- Prof. Bernhard Baune

Functional recovery is the new target of treatment
of depression - Farid Aslam Minhas

We must sympathize with the patient and give them
hope which we are not doing - S. H. Shafqat

KARACHI: We require novel approaches to treat depression. New anti-depressants have multimodal approach, they are effective in treatment of depression symptoms, are well tolerated and they are effective in broad range of patients. This was stated by Prof. Bernhard Baune Professor of Psychiatry at University of New South Wales, Sydney Australia. He was making a presentation on “Reframing the Treatment Goals of Depression” at Karachi on December 12, 2017. The meeting sponsored by Lundbeck was jointly chaired by Prof. Syed Haroon Ahmad and Dr. Unaiza Niaz two eminent psychiatrists of the country and it was very well attended by psychiatrists, neurologists, physicians and other healthcare professionals. Dr. Majid Abidi acted as the Moderator in the first session while the second session was moderated by Prof. Sohail Ahmad.

Members of the Experts panel at Lundbeck meeting at Karachi photographed from (L to R) are Prof. Ejaz
Ahmad Vohra, Pros. S. H. Shafqat, Prof. M. Wasay, Prof. Zaman Sheikh and Prof. Ghulam Rasul.

Prof. Bernhard also talked about brief history of psychiatry as well as evolution of antidepressants. Psychiatry he said has moved from private to public and then individualized public.  Over the years we have come a long way to de-hospitalization of psychiatry. In the past new drugs used to be licensed and made available within a year but now it takes fifteen to sixteen years due to too much controls by the regulatory agencies. First we had the TCAs which were followed by SSRIs and NSSRIs, AGO, Vil and then in 2013 came the VOR in the market. We have made lot of progress with the new drugs. There is change in molecule structure and different underlying functions. The anti-depressants can be classified into first, second and third genereation medications. He then referred to the CANMAT 2016 Depression Guidelines as well as Australia New Zealand Guidelines for treatment of depression. He emphasized that it was the dose of the drug which makes it poison or remedy. Hence, we need to use the right dose, for right treatment, in right patients and also use drugs which are safe and effective and not toxic.  Drugs with these characteristics should be preferred.

Continuing Prof. Bernhard said that use of SSRIs are effective in over 60% of depressed patients. Some patients may need a combination of SSRI and SNRIs. He then referred to the discovery of Vortioxetine a new anti-depressant which offers multimodal treatment. It offers increased neurotransmission in several symptoms thereby changing not only mood but also decreasing depression. It enhances glutamite activity. It contracts some of the negative feedbacks systems to maximize full treatment affect. The participants also actively participated in the discussion using the information technology and specially created App. Voting showed that over 53% of those present used Rating Scale in clinical practice to treat depression. He briefly referred to the Golden measure of depression including Hamilton Depression Rating Scale and FAST which  stands for Fastest Assessment Short Test to measure anxiety, occupational disorders, and cognitive, financial, interpersonal relations. On paper Prof. Bernhard opined all anti-depressant are effective but we know that they all do not work the same way. We must know this difference so that we can have a rational model.

Lundbeck organized a series of interactive symposia on Multimodal approach to treatment of depression
with Functional recovery in major cities recently. Group photograph taken at the Karachi meeting shows
the guest speaker Prof. Bernhard Baune, chairpersons Prof. S. Haroon Ahmad and
Dr. Unaiza Niaz along
with senior executives of Lundbeck and some of the participants.

Speaking about the short term trials with Vortioxetine he pointed out that nine thousand seven hundred patients were involved in the clinical programme in seventeen studies. This agent addresses mood, cognition, and functioning was also looked at in clinical development programme of this drug. It improves mood symptoms, with major depressive disorders. It reduces depression and anxiety level which are all improved with this medication. The patients start feeling better within eight weeks even it works in elderly those sixty five years of age and above. Studies have showed that short term efficacy is maintained with continuous treatment. He then shared the results of a Meta-Analysis of short term studies which looked at depressed and anxious patients and improvement of their cognitive performance.  It has a unique pharmacological profile which is translated into unique clinical profile. CONNECT study showed that it improves every day function. Talking about its safety and tolerability profile Prof. Bernhard mentioned that nausea and headache were the most common adverse effects. Sexual dysfunction is not related to this drug. In fact it improves depression as well as sexual function. There is no weight gain, no sleep disturbances and another advantage of this drug was that it can be taken anytime of the day.

Prof. Farid Aslam Minhas another noted psychiatrist from Rawalpindi Pakistan was the other speaker in this session whose presentation was on “From Mood to Function-New Goal of depression treatment”. He discussed in detail the emotional implications in cognitive mood disorders, unmet needs in depression treatment in detail. He pointed out that depression was the leading cause of disability globally. It impairs work functions, it diminishes the ability to think. Depression is more than just low mood even in remission stage 21% are still affected and 85% of depressed patients face sleep problems. Depression is a heterogeneous disorder. He then discussed in detail about emotions, physical and cognitive symptoms and pointed out that if we miss any symptoms, we are likely to miss some patients.  With the anti-depressants available in 70s, depression symptoms used to reduce by 70% but in 1990s remission from symptoms which persist was the goal. However in 2010 full functional recovery is possible with the use of new anti-depressants. We need to treat emotional, cognitive as well as physical symptoms. With the new drugs, they are all treated and full functional recovery is achieved.

Talking about understanding cognitive functions, Prof. Farid Aslam Minhas remarked that 52% of depressed patients report impairment of their cognitive functions. They suffer from forgetfulness, lack of confidence, are tired, lethargic. They do not understand what their doctor is telling them. They cannot do different tasks and they have no short term memory. In acute phase, 94% of the patients complain of cognitive impairment which is reduced to 71% in response phase and 44% in remission state. Referring to different studies he stated that almost 70% of patients suffer from cognitive impairment. Our own study showed that 63.3% of depressed patients had cognitive impairment while a study in Karachi by Prof. Iqbal Afridi and his colleagues showed similar findings as regards cognitive impairment in depressed patients. Neuro inflammatory changes, Prof. Farid Aslam Minhas remarked, takes place in depression. If early diagnosis is missed, it is very difficult to treat these patient later on and achieve full recovery. To start with 60-90% remission will be seen in one year but 50-70% of these patients will have a subsequent episode if they are not treated properly. He advocated the integration of depression in primary health care and general healthcare set up. Inadequate anti-depressant response means failure to previous treatment which is then difficult to treat.

Prof. S.H. Shafqat an eminent Cardiologist was presented Life Time Achievement Award
by Lundbeck at its symposia on Depression held at Karachi recently. Picture shows
Prof. S. Haroon Ahmad along with Dr. Unaiza Niaz and Prof. Raza Ur Rehman
presenting him the memento
on this occasion.

Depression, Prof. Farid Aslam Minhas further stated does not come alone, it has comorbidity with diabetes mellitus as well as cardiovascular diseases. There is recurrence of myocardial infarction in depression. If ADHD is missed in the children, they suffer from depression in their adulthood. ADHD is most often missed because we do not have adequate number of qualified child psychiatrists and their number is not more than three or four in the whole country. When ADHD is missed, it is not treated. Speaking about the factors affecting inadequate response to anti-depressants he mentioned elevated BMI and depression, increased body weight which is associated with response to anti-depressants treatment. Greater body weight is also related with chronic major depression, more body weight will result in metabolic syndrome. Residual symptoms increase relapse. Many patients stop treatment due to side effects of drugs which are an important barrier to achieve remission. Low remission rate, persistent symptoms and side effects are major barriers to achieve complete remission. He concluded his presentation by stating that depression is a multidisciplinary disorder and functional recovery is the new target of treating depression.

In the second part of the meeting which was moderated by Prof. Sohail members of the experts panel briefly talked about treatment of depression and its co-morbidity. Prof. M.Wasay consultant neurologist form AKU said that neurologists see lot of cognitive symptoms with depression in their practice. Almost 30% of elderly patients and 25% of stroke, dementia patients suffer from depression. SSRIs are commonly used in neurology departments. The patients respond very well. They are treated usually for three to six months and it is also combined with rehabilitation.

Prof. Ejaz Ahmad Vohra from Ziauddin University pointed out that depression  associated with a number of other chronic diseases like diabetes, stroke as a comorbidity is not an uncommon condition. However, recognition in stroke is a problem. In diabetics depression affects treatment. Prof. Zaman Sheikh remarked that psychological problems in diabetics are common, diabetes and depression, dyslipidemias go together. Complications do occur. We use anti-depressants for treatment but life style is not taken seriously with the result that depressed  patients go on eating, develop obesity, gain weight and are then more depressed. They do not go for exercise because of depression, they forget to take medicines and also start smoking. Prof. Raza Ur Rehman from DUHS stated that cognitive symptoms of depression need to be treated, we use these drugs for anxiety related dysfunctions as well. Restoration of functions is very important for any drug. Brig. Shoaib said that SSRI, SNRIs are much better than TCAs. This drug has a multimodal molecule, hence it is going to be effective in all depression disorders and hopefully it will become a broad spectrum anti-depressant. Prof. Ghulam Rasool from Quetta said that depressed patients cannot work as their intellectual capability is affected, many complications also take place. So far with the use of TCAs, SSRIs, and SNRIs we have been facing problems and hopefully this new drug will be more beneficial.

Prof. S. H. Shafqat an eminent cardiac physician participating in the discussion stated that cardiac patients also suffer from many psychiatric disorders. Treatment of depression will ensure better prognosis in cardiac patients. In the past, he recalled, we the doctors used to treat all patients, then different sub-specialties came in and I as a Director of JPMC bifurcated the Neuropsychiatry ward in to Neurology and Psychiatry ward. Hence, we have made lot of progress. He regretted that we ourselves produce depression when we do not thank for what we have got but always complain of what we could not get or achieve. Our new generation is much more affluent, has more resources as compared to our past generations but even then we do not thank God almighty. We in our childhood had very little food to eat but now it is in abundance. The new generation do not realize how lucky they are and our economy has improved a lot. However, we used to get pure food but now it is adulterated. It is our duty as physicians to talk about these things but we do not talk about it. We must remember our history. Instead of giving any advice to the patient, we refer them for angiography. What is more important is that we must sympathize with the patient and give them hope which we are not doing.

Dr. Unaiza Niaz highlighted some very important issues and asked numerous questions to  the guest speaker Prof. Bernhard Baune. She pointed out that one must add mood stabilizers with anti-depressants and do not give anti-depressants which are stimulants. The family should be asked to keep an eye on these depressed patients. Responding to a question from Dr. Unaiza Niaz, Prof. Bernhard remarked that Vortioxetine was not a stimulant. At this she said that it will then be equally effective in bipolar depression. Prof. Bernhard further stated that there are no reports of high mood with the use of this drug. Responding to yet another question from Dr. Unaiza Niaz, Prof. Bernhard said that cognition gets better and improvement is visible in a weeks’ time with this drug. Since it does not enhance cognition, it cannot be abused either. Prof. Syed Haroon Ahmad remarked that we must treat depression at least for a year. With this new agent the cognition functions will be improved and he hoped that it will be affordable for the common man.

Earlier Dr. Majid Abidi in his introductory remarks said that today’s meeting was a part of CME programmes by Lundbeck. We have just four hundred fifty psychiatrists and one hundred thirty neurologists for a population of over two hundred million people. We have limited budget for mental health services, hence there is need for increased health education and awareness about mental healthcare. Depression is going to be No.1 cause of disability and almost 90% of depressed patients also suffer from cognitive functions.

Later the organizes also honoured Prof. S. Shafqat with a Life Time Achievement Award while all the speakers and members of the expert panel were also presented traditional Sindhi Cap and Ajrak.

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