Sharing Knowledge of Cognitive Dysfunction in Depression

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 Celebrating 100 Years of Lundbeck

Sharing Knowledge of Cognitive
Dysfunction in Depression

By Shaukat Ali Jawaid

ISLAMABAD: In order to celebrate One hundred Years of its establishment Lundbeck Pharmaceuticals organized a daylong symposium cum workshops here on September 19th 2015 to share knowledge of cognitive dysfunction in depression. It was very well attended by eminent mental healthcare professionals from all over the country.  Speaking in the inaugural session Mr. Lars Nelleman Vice President and Managing Director, Clinical Development Center for Asia of Lundbeck introduced THINC which stands for “To educate, Highlight and Integrate New Thinking on Cognitive Dysfunction in Depression”.  Lundbeck, he said, has been supporting this project since it started few years ago. This is related to our area of interest and we have some new products in pipeline, he remarked.

This was followed by unlocking the Lock of Depression by Prof. Khalid Mufti, an eminent psychiatrist and former President of Pakistan Psychiatric Society.  Prof. Nassar Sayeed Khan in his introductory remarks said that we are missing in our whole treatment strategy the problems the patients face after taking medication.  This is something which is left behind and this problem is not addressed properly.  Lundbeck is addressing this issue of cognitive dysfunction. Remission in psychiatric disease, he said, is always controversial. Recovery is different than remission but how to assess it is an objective phenomenon.  It is always a controversial situation. If we go back to 50s; the treatment strategy has changed from response to remission with SSRIs. Now we talk about ideal outcome of functional level cognitive functions. Treatment comprises functional recovery in depression.


Prof. Nasar Sayeed Khan was the moderator of the THINC symposium
organized by Lundbeck at Islamabad recently. Picture shows
Prof. Sultan, Prof. Khalid Mufti, Mr. Aslam Sheikh,
Prof. Mowadat H. Rana and Prof. Farid Aslam Minhas
presenting the memento to Prof. Nassar Sayeed Khan.

Prof. Farid Aslam Minhas from Institute of Psychiatry, Rawalpindi talked about role of Cognitive dysfunction in depression.  Patients after treatment, he said, should come out of cognitive dysfunction. We need to create awareness about it.  We must know How to interact with each other and how to think about it.  He then highlighted the symptoms of cognitive impairment, its effects on functioning of the patient. Attention, Memory, Executive Functioning, Psychomotor speech, he said, are the four main domain in which we see our patients.  Patients do not listen what you say because patient’s cognition is not there.  Patient is not recognizing what you are saying. The patient will often say, tell me again doctor what you have said? In Executive Function he does not get treatment.  He or she lacks confidence, cannot make decision. They are disturbed.  The patient is tired, lethargic, walks up and goes slowly. Almost 94% of the time patient spends with cognitive symptoms which have been shown by various studies. His thinking is slow and he has low concentration.  Another study has showed that 70% of patients have cognitive impairment.  In severe depression, the patient has severe cognitive impairment.  A study by Prof .Iqbal Afridi and his colleagues from JPMC Karachi showed that 63.3% of patients had cognitive impairment. A study from China showed that 52% patients had cognitive impairment and functional disability.  Yet another study showed that with SSRIs, 78% of patients were getting better but their cognitive functions were not getting better and they suffered from functional disability. They won’t return to their functional level. Psychotherapy, Prof. Farid Aslam Minhas said, has an important role in depression but in cognitive dysfunction it does not work. Patients do not understand. He then talked about different scales to assess cognitive dysfunction.


Lundbeck organized a symposium in Islamabad entitled THINC to celebrate its 100 Years.
Group photograph taken on the occasion shows the participants with the moderator,
facilitators and the faculty members.

During the discussion the lack of availability of assessment tools was also highlighted.  Prof. Farid Aslam Minhas said that they use British Columbia Scale. Prof. Khalid Mufti remarked that these scales should be validated in Pakistan. We should know how to prevent and treat these disorders in a context in which we see our patients. How much time we give to our patients and what will be the outcome. We are not treating patients the way we should be treating.  Prof. Nassar Sayeed Khan agreed that we are not spending enough time with the patients. Prof.Sultan Ahmad opined that cognitive dysfunction in depression is an important area. Prof. Khalid Mufti said that better outcome will be patient’s clinical functional ability. We have to look at the cultural part, educate and make our patients understand as leaders thereby filling the moral gaps.

Hot and Cold Cognitive
Impairment in Depression

Prof. Rizwan Taj from PIMS Islamabad talked about Hot and Cold Cognitive impairment in depression. It comprises a major chunk of mental health issues. It affects across age, cultures and history.  These patients suffer from disturbance and disability for months and years. This is not going to go away, hence we need to find ways and means to help our patients. Hot and cold, he said, is an interesting concept. Cognitive impairment in depression is a norm and not exception, hence we need to always think about it. Attention, Memory learning, Executive Functioning and emotional expressing are all domains of cognition.  Cold cognition is non-emotional. Hot cognition involves negative attention bias and over response to negative feedback.  These patients have increased perception for negative feedback. Negative attention bias is a hot cognitive problem associated with depression.  He also referred to emotional processing and pointed out that cognitive deficit is associated with high relapse rate and poor functional outcome.  It is organic. Neuropsychiatry, he opined was a good topic for research. It requires better understanding. There are Better ways to deal it.  He also referred to possibilities of using antidepressants and then remarked we must look whether it increase the risk of dementia.

During the discussion it was pointed out that cognitive impairment is more common in women and young males.  If young women are affected, it will also affect the young children. Hence it is important that mother is well which is essential for the welfare of the family. Prof.Mazhar Malik remarked that emotional symptoms are related with negative symptoms.  After these two presentations and discussion the participants were split in three groups for the interactive workshops which were facilitated by Dr.Asad Tameezuddin, Prof. Mazhar Malik and Dr. Wajid Ali Kwanzaa from Peshawar.

Patients suffering from cognitive dysfunction, Prof. Mazhar Malik said, look sad, they lose interest. They even cannot do simple things. They have feelings of forgetfulness, suffer from guilt feelings. They lack concentration. Most of their symptoms are around memory and emotional behaviour. Hot symptoms are emotional while cold are functional. Later the group leaders made brief presentations on the discussion in their respective groups.


A view of the THINC Workshop in progress at Islamabad organized by Lundbeck.

Dr. Mian Iftikhar representing his group said that patients with cognitive dysfunction suffer from detraction in performance, forgetfulness, and negative perceptions, lack of attention, concentration, and feeling of helplessness and also have guilt feelings. He also referred to the British Columbia assessment scale and Digital Symbol Subtraction Test. Dr. Asad Tameezuddin in his presentation said that cognitive dysfunction varies in different age groups, education; culture has a lot to do with this. We need to keep in mind all these things.  Hot and cold is a new concept. More research data is required to be incorporated in management of depression. Imported assessment scales are not sufficient. We need culturally sensitive indigenous assessment scales and detailed assessment of patients is required. We need simple assessment scales which are easy to use, he added.

Dr. Wajid Ali Kwanzaa presenting recommendations of his group referred to the couplets narrated by Prof. Nassar Sayeed Khan and then recited the following couplets before making his presentations:

 

Dr. Khanzada was of the view that we should ask patients about memory problems, problems with household jobs, problems in decision making.  He was of the view that not all patients suffering from depression suffer from cognitive dysfunction. Most people do not show it the same way. More incidence of depression results in greater cognitive dysfunction. We also need to look at whether antidepressant therapy also causes any cognitive dysfunction, he added.

Prof. Nassar Sayeed Khan said that recognition of cognitive dysfunction requires awareness. Depression is a multifactorial disease.  We need to take a comprehensive view. We were not aware of cognitive dysfunction earlier; hence we did not ask the patients about it. It is a new concept. We must find out whether we need new tools to assess this? All these problems i.e. emotional, functional, cognitive, he stated, need to be addressed on one assessment tool. Then these tools need to be valid, reliable and sensitive. We usually do not administer these scales in clinical practice. Referring to Digital Symbolic Sensitive Test, he said that we need quick, brief tool which can be used in clinical practice. The participants were then again split in three groups for interactive workshop on recognizing depressed patients with cognitive symptoms. The facilitators for these interactive workshops included Dr. M.Irfan, Dr. Imran Dogar and Prof.  Iqbal Afridi.

Col. Nadeem making presentation on behalf of their group talked about characteristics of anti-depressants. He also referred to life style changes, psychotherapy and avoiding self-medications. He also spoke about the role of faith and spirituality and opined that we must plan daily activities of the patient and work on motivation. He also referred to the role of caregivers and family members which was very important.

Prof. Iqbal Afridi speaking on behalf of their group referred to healthy diet, ensuring that the patient sleeps well. He also talked about their hygiene and other environment factors, music and art therapy, CBT, Info care, negotiating treatment at every step, assuring drug adherence, identification, documentation, encouraging the patient, reassessing the patient and their activity scheduling.

Dr. Irfan speaking on behalf of their Group talked about enhancement of social skills, differences in various antidepressants i.e. TCs, SSRIs, NSSRIs, their side effects and other biological treatment modalities. Belief system and family system, he said, were also very important. He then talked about development of insight, re-treatment after re-assessment, investigations and looking after co morbidities. He emphasized the importance of tailor made treatment for individual patients.

Prof. Mowadat H. Rana in his presentation remarked that mental healthcare professionals are unique professionals hence we should take pride in it.  Psychiatrists have an advantage. They should not look at the disease of mind only and intervention. He discussed in detail non-pharmacological, social, spiritual interventions, ECT, role of anti-depressant as well as liaison psychiatry. We need to solve the problems of our colleagues. Referring to the patient’s psychology he said that if we have floods in Pakistan, some may think it is the punishment of our sins, others may also have some guilt feelings. How these disasters occur. It reflects the mindset of patients which should be kept in mind. We must know how and when to intervene for reversal of this factor. After CBT, the patient starts to contribute to something, starts working for others, helping development of others; he or she will feel better. Hence let them start intervening in other people. He then referred to the importance and significance of Benzodiazepines used with anti-depressants.  Almost 70% of patients suffering from depression also suffer from anxiety. It is important that while using benzodiazepines with anti-depressants, Benzodiazepines should be stopped after five weeks. Never use them for more than five weeks.

While treating co-morbidity with depression, we are not looking at patient in isolation.  He may be suffering from CAD, diabetes mellitus, hypertension, anemia, malignancy or malnutrition.  We must keep these things in mind while treating depression. We must also know what their effect on cognitive area is? We have been raising awareness about depression since many years. Many of our professional colleague’s   i.e.  Physicians, cardiologists, gastroenterologists go on prescribing anti-depressants. SSRIs are being prescribed for distress of these patients and not for depression.  Prof. Mowadat Rana opined that distress should be separated from depression. Distress should never be treated with anti-depressants. Over prescription of anti-depressants by our other professional colleagues is not correct and was dangerous. We must help our colleagues to become rational in their prescriptions and find an appropriate key to unlock depression.

Non-pharmacological management of
cognitive dysfunction in depression

Prof. Syed Sultan from Peshawar made a presentation on non-pharmacologic management of cognitive dysfunction in depression.  He was of the view that we must avoid information over dose to the patient.  Use short sentences while talking to them. We need to encourage, educate the patient. Behavioral activation, he opined, was a powerful tool. There is a significant level of clinical evidence that Yoga, Meditation, Getting out with Friends, Clear of drugs, faith and religion, five  times prayers a day all work. CBT in cognitive therapy is time limited. He also talked about the effects of CBT and its limitations. CBT is time consuming and complex, it requires competence and training.  Everybody cannot do CBT. Mindful mind management is better than CBT without training. Problem solving therapies’ are good in depression. Antidepressants relieve symptoms but treatment should also improve the patient’s quality of life. There is lot of room for research .CBT is an effective treatment, he added.

Prof. Farid Aslam Minhas in his second presentation discussed management of cognitive dysfunction in depression.  Cognitive impairment, he said, is common in patients with depression.  Negativity impacts functioning and treatments.  Management of depression should include treating cognitive impairment. If the patient’s condition is serious, it is going to have serious problems and it will impact the whole treatment.  Speaking about psycho stimulants and cholinesterase inhibitors, he said that there is no treatment in depression as monotherapy.  These drugs can be combined with anti-depressants.  There is limited efficacy of combination treatment with anti-depressants.  If these drugs are used, the patients feel excessive day time sleepiness, it does not improve cognitive symptoms in depression but they are first line of treatment in ADHD. No anti-depressants are recognized for treatment of cognitive dysfunction in depression.  Some anti-depressants show pro cognitive effects. Distress and disease is a natural process in depression. If stress continues for too long, some changes will take place. He then described the mode of action of cognitive impairment. Many existing anti-depressants, he said, improve cognitive functions by improving mood and depression symptoms but these studies have been on very few patients which are some of their limitations.

He then talked about FOCUS study which enrolled patients between the ages of 18-85 years.  Total patients enrolled in this randomized double blind placebo control study were six hundred two. The dosage of 10-20mg was associated with improvement in cognition system at eight weeks irrespective of the dosage used. With the use of ECT cognitive functions are impaired but it comeback after three months of the last ECT episode. ECT, he opined, is effective in depression.  Vagal nerve stimulation is used for the treatment of refractory depression in United States. ECT leads to remission in almost 52% of patients.  He was of the view that one should not under estimate the value of psychological treatment. It can be done by midwives, nurses who are trained. We will have to find our own methods to treat. Trained nurses are as good as trained psychotherapists. He concluded his presentation by stating that cognitive impairment prevalence is quite high. It is a common symptom in depression and new treatment approaches are required to manage this.

Prof. Mowadat Rana said that cognitive dysfunction in depression is treatable. These depressed patients also suffer from poverty of illiteracy and relationship poverty.  These are the most manageable psychiatric disorders. Depression comes with two other situations i.e. poverty of relationship as many people run away from these patients. It also comes with illiteracy. Prof. Khalid Mufti in his concluding remarks thanked all the participants and the presenters in particular and concluded his address with the following couplet:

 

Dinner Reception at
Danish Embassy

The participants of the symposium also enjoyed the diner reception hosted by the Danish Embassy at the Ambassador’s residence.  Speaking at the occasion  Mr.  Lars Nelleman Vice President for Clinical Research and Development in Lundbeck based at Singapore said that the company has remained busy in research in Parkinson’s disease, Alzheimer’s disease, schizophrenia, epilepsy, depression etc., which are  our areas of interest. M.Aslam Sheikh Country Manager of Lundbeck in Pakistan in his speech said that Lundbeck specializes in brain research. The company was founded by Mr.Lundbeck on August 14th 1915 and he got married to the first employee of the company he recruited. At present there are about seven hundred million people with brain diseases.  Lundbeck employs over six thousand employees all over the world and 70% of its shares are owned by Lundbeck Foundation.  It is the largest pharmaceutical company active in brain diseases research and we are 42nd ranking in the world in the field of pharmaceuticals. We are leaders in the field of psychiatry and neurology and we dare to be different. He also disclosed that Lundbeck organized 154 scientific meetings in Pakistan during 2014 training over three thousand healthcare professionals.   We take care of our employees. We follow code of ethics and always uphold professional ethics in marketing. Ethical values are very dear to us. Replying to various questions M.Aslam Sheikh said that despite the fact that some of the products they were marketing in Pakistan had very low price but even then they continue to make them available for the benefit of mentally ill patients. For anti-Parkinson’s drugs and many other molecules are now in the pipeline.  The same was the situation as regards long acting anti psychotics and pricing is the real issue.  We have applied for many new drugs for registration and our applications are pending with the DRAP. Responding to yet another question regarding the Lundbeck Institute and its cooperation Mr. Aslam Sheikh said that we wish to have more representation from Pakistan but at present the situation does not permit visit of speakers from the Lundbeck institute. However, as soon as the situation improves, we are determined to increase our interaction between the Lundbeck Institute and mental healthcare professionals in Pakistan.

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