P.2.b.035
Understanding cognitive dysfunction in depression in primary and
secondary care in the UK: a multi-step consultation with clinicians
Allan H Young,1 Kate Bones,2 Guy M Goodwin,3 John Harrison,4 Cornelius Katona,5 R Hamish McAllister-Williams,6
Jill Rasmussen,7 Sarah Strong8
King’s College London, London, UK; 2Sussex Partnership NHS Foundation Trust, Worthing, UK; 3Oxford University, Oxford, UK; 4VU University Medical Center, Amsterdam,
the Netherlands; 5University College London, London, UK; 6Newcastle University, Newcastle, UK; 7Lingfield, Surrey, UK; 8Depression Alliance, Croydon, UK
Figure 2: Statements on detection of cognitive dysfunction in depression, and responses.
Cognitive dysfunction in depression is poorly understood by health-care professionals
16
Cognitive dysfunction in depression is more likely to be detected in secondary care (eg by psychiatrists) than in primary
care (eg by GPs)
17
Cognitive dysfunction in depression remains an area of unmet need
18
There is a lack of readily available tools for detection of cognitive dysfunction in depression
19
Patients are commonly asked only subjective questions to determine the presence of cognitive dysfunction in depression
20
Patients with depression should have access to routine cognitive assessment
21
Further research is required to understand the cost-effectiveness of formal detection of cognitive dysfunction in depression
22
In older patients (>55 years) with mild cognitive problems, depression should be considered as a possible diagnosis
Methods
Agree
100
Don’t know/uncertain
90
●● Using a multi-step consultation process, we obtained and evaluated the views of primary and secondary care
experts in depression.
Responses (%)
80
–– Step 1: a multi-stakeholder steering committee (including psychiatrists, psychologists, primary-care
physicians, and representatives from occupational therapy and a depression charity) provided the key
themes of burden, detection and management of cognitive dysfunction in depression and, through
round-table discussion, developed ~10–15 statements on each.
66
60
40
S14
S15
Ps GP
yc
h
–– Step 2: these statements formed an online survey (hosted by medeConnect, part of Doctors.net.uk)
completed by 200 health-care professionals (100 general practitioners [GPs] and 100 psychiatrists) with
an involvement in the management of depression.
Ps GP
yc
h
0
Ps GP
yc
h
20
»» The steering committee was initiated and supported by the pharmaceutical company Lundbeck Ltd,
through an educational grant. Lundbeck Ltd had no input or influence on content.
»» Participants had to have seen a minimum number of patients with major depressive disorder in the
previous 3 months (GPs >10 patients, psychiatrists >20 patients).
Disagree
Ps GP
yc
h
●● We explored understanding of cognitive dysfunction in depression (major depressive disorder) among
UK clinicians.
15
Ps GP
yc
h
●● Currently, cognitive dysfunction in depression is largely unrecognised, unmonitored and untreated.
There is a lack of awareness that cognitive dysfunction in depression is an issue
Ps GP
yc
h
●● Research suggests that cognitive dysfunction is highly prevalent in people with depression and has a
significant impact on their functioning.3
14
Ps GP
yc
h
●● Cognitive dysfunction is an important aspect of depression that includes problems with thinking,
concentration and memory.1,2
Ps GP
yc
h
Introduction
Ps GP
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1
S16
S17
S18
S19
S20
Statement number (GP / psychiatrist responses)
S21
S22
Management
»» Level of agreement with the statements was noted as “Strongly disagree”, “Disagree”, “Agree”,
“Strongly agree” or “Don’t know/uncertain”.
●● Management of cognitive dysfunction in depression was the area of biggest disagreement among clinicians.
There was High/Very high agreement from GPs and/or psychiatrists for just seven of the 12 statements
(Figure 3).
»» H
igh agreement 66%, Very high agreement 90%.
Figure 3: Statements on management of cognitive dysfunction in depression, and responses.
–– Step 3: the steering committee reviewed responses from step 2 and highlighted priority areas for future
education and research.
Results
Burden
●● There was High/Very high agreement from both GPs and psychiatrists for all except three of the statements
(Figure 1).
Figure 1: Statements on burden of cognitive dysfunction in depression, and responses.
1
Cognitive dysfunction in depression occurs in thinking, memory, executive function and concentration
2
Cognitive dysfunction in depression is independent of depressive symptoms
3
Problems with thinking, concentration and memory have a clinically significant impact on a patient’s life, at presentation,
during treatment and after response to treatment
4
Cognitive dysfunction in depression is associated with impaired occupational function, even when depressive symptoms
may have improved or remitted
5
Cognitive dysfunction in depression is associated with impaired social function
6
Cognitive dysfunction in depression is associated with impaired marital function
7
Cognitive dysfunction in depression is associated with impaired parental function
8
Cognitive dysfunction in depression reduces the patient’s confidence
9
Cognitive dysfunction in depression adds to the economic burden on the individual (eg reduced earning potential
because of difficulty in gaining or maintaining employment, or reduced ability to manage household finances)
10
Cognitive dysfunction in depression is associated with increased costs to society (eg reduced productivity, increased use
of health-care resources, and family or relationship difficulties that may lead to divorce or family break-up)
11
More than 30% of patients experience persistent cognitive symptoms despite remission of depressive symptoms
12
Recovery of cognitive function is less likely following repeated episodes of depression
13
Further research is required to understand the burden of cognitive dysfunction in depression
Agree
100
Disagree
There is current uncertainty about the best-practice management of cognitive dysfunction in patients with depression
24
The effect of cognitive behavioural therapy on cognitive function in depression has not been formally studied*
25
There is no evidence to support the effect of cognitive training or behavioural activation on cognitive function in depression*
26
There is no evidence to support the effect of exercise on cognitive function in depression*
27
There is a lack of evidence for the effect of lifestyle changes on cognitive function in depression*
28
Improvement in cognitive dysfunction does not occur with all antidepressants
29
Investigation of the effects (positive and negative) of antidepressants on cognitive dysfunction in depression should
be prioritised
30
Cognitive dysfunction should be re-assessed 4–6 months following cessation of antidepressant treatment
31
Clinical recovery of depression is not always associated with recovery of cognitive function
32
Persistent cognitive dysfunction following recovery from depression is a predictor of increased risk of relapse
33
Cognitive dysfunction should be monitored throughout the course of depressive illness and during long-term follow-up
34
The presence of significant cognitive dysfunction should be considered when formulating an individual patient’s
treatment plan
*30–50% responded “Don’t know/uncertain”
Agree
100
Disagree
Don’t know/uncertain
90
Responses (%)
80
66
60
40
Ps GP
yc
h
Ps GP
yc
h
S26
S27
S28
S29
S30
S31
Statement number (GP / psychiatrist responses)
Ps GP
yc
h
Ps GP
yc
h
Ps GP
yc
h
Ps GP
yc
h
S25
Ps GP
yc
h
S24
Ps GP
yc
h
Ps GP
yc
h
S23
Ps GP
yc
h
Ps GP
yc
h
0
Ps GP
yc
h
20
S32
S33
S34
Conclusions
Don’t know/uncertain
●● This consultation provides insight into the level of understanding of cognitive dysfunction in depression by GPs
and psychiatrists in the UK.
●● Most respondents recognised the marked negative impact that cognitive dysfunction has on outcome and
functioning in patients with depression.
●● There is uncertainty as to whether cognitive function improves when depressive symptoms resolve.
●● There is a need for tools that can be easily used in the clinic to facilitate the objective assessment of cognition,
both in primary and secondary care.
●● There is a high level of uncertainty around best practice for the management of cognitive dysfunction, a likely
consequence of the lack of high-quality data available in this area.
90
80
Responses (%)
23
66
60
40
20
Ps GP
yc
h
Ps GP
yc
h
Ps GP
yc
h
Ps GP
yc
h
Ps GP
yc
h
Ps GP
yc
h
Ps GP
yc
h
S3
Ps GP
yc
h
Ps GP
yc
h
S2
Ps GP
yc
h
Ps GP
yc
h
S1
Ps GP
yc
h
Ps GP
yc
h
Recommendations
0
S4
S5
S6
S7
S8
S9
S10
Statement number (GP / psychiatrist responses)
S11
S12
S13
●● Education of UK clinicians regarding cognitive dysfunction in depression is required, as is further research into
its assessment, treatment and monitoring.
Acknowledgements
This work was supported by Lundbeck Ltd. Under the authors’ conceptual direction, medical writing assistance for this poster was provided by Karen
Brayshaw at Complete HealthVizion.
Detection
●● There was High/Very high agreement from both GPs and psychiatrists for seven of the nine statements
(Figure 2).
References
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. DSM-5. Washington DC: American
Psychiatric Publishing, 2013.
2. Hammar Å, Årdal G. Front Hum Neurosci 2009; 3: 26.
3. Jaeger J et al. Psychiatry Res 2006; 145: 39–48.
Disclosure statement
AHY, GMG, JH, CK, RHMW and JR received honoraria, grant funding and consultancy payments from pharmaceutical companies including H. Lundbeck A/S. KB and SS have no conflicts of interest to disclose.
29th European College of Neuropsychopharmacology Congress, Vienna, Austria, 17–20 September 2016