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Chairman Guy Goodwin introduced not only the speakers but also the audience to Pigeonhole live – the audience being enthusiastically encouraged to make use of their smart phones throughout this interactive meeting both to ask and answer questions via this medium. Traditional question cards were provided for the technologically-challenged!
Cognition needs to be treated differently from the other symptoms associated with MDD, Professor Raymond Lam, University of British Columbia, Canada, told the audience. Cognitive dysfunction in patients with MDD often persists into remission, and it is recognised that cognitive impairment drives functional impairment and, in particular, poor work functioning. This in turn means that patients who return to work are often working sub-optimally and this has associated costs – both financial costs for society but also costs in terms of the patient’s wellbeing. Work is important to patients, not just because of the money they earn – but as a source of accomplishment, intellectual stimulation, regular activity and social interaction.
As cognitive deficits affect a patient’s ability to functionally recover, new treatment options are needed to target cognitive dysfunction and better improve functional outcomes in patients with depression.
Which test is best in the assessment of cognitive dysfunction in MDD? This was the question posed by Dr John Harrison, VU University Medical Center, Amsterdam, The Netherlands and Metis Cognition Ltd.
An ideal test should be reliable, sensitive, valid, suitable for use in the long term, available in parallel forms and suitable for cross-cultural use. Dr Harrison cautioned the audience to do three things: choose the test to answer the question you want answered, remember that exploration informs confirmation and, most importantly, never be a slave to dogma. As he explained, tests to assess cognitive functioning in Alzheimer’s disease are insufficient and prone to a number of problems, yet they failed for 20 years because researchers were slaves to dogma!
In an assessment of the FOCUS study, cognition was successfully evaluated using the Digit Symbol Substitution Test (DSST) – suggesting that this would be a good candidate test for the assessment of cognitive dysfunction in MDD.
Interestingly, a Pigeonhole survey conducted during the meeting suggested that 70% of attendees already investigated cognitive deficits in their patients with MDD on a regular basis. However, 30% of attendees did not assess cognition regularly in their patients with MDD. Maybe those that don’t currently assess cognition in depression will find the THINC® Cognition Tool of interest.
Despite the increasing recognition of the importance of the assessment of cognition in MDD, as Professor Roger McIntyre, University of Toronto, Canada reported, no accepted and validated screening tool for the objective and subjective assessment of cognitive dysfunction in MDD suitable for use in daily clinical practice is currently available. Indeed, as he stated, what is needed is a tool to measure the extent of a deficit, not just aid in its identification.
This is the underlying rationale for the development of the THINC® Cognition Tool - a tool specifically developed to detect and measure cognitive dysfunction in MDD. The THINC® Cognition Tool incorporates several brief, easy to administer objective tests including the DSST, Choice Reaction Time (CRT), the Trail Making Test B (TMT-B), the One-Back Test (1BT) and the Pathfinder test as well as a subjective, patient reported assessment PDQ test. During the symposium a video demonstrating the objective tests was screened – showing the tests to be attractively designed and appealing to perform.
Currently, the THINC® Cognition Tool is being validated for the screening of cognitive dysfunction in adults with depression at the University of Toronto, Canada. It (along with many other useful materials concerned with cognitive deficiency in MDD) will be available to download from the THINC® website soon (THINCcognition.com). The tool will be free of charge and should be also be available in local languages.
‘Cognitive dysfunction in depression: are we THINC®ing about it enough?’ was the title of a well-attended satellite symposium sponsored by Lundbeck which took place on Sunday afternoon.
Access to a small number of data packages for candidate agents has already been attained and interest in some of the 9 drugs so far collected is already apparent.
Over the past three years, The Medicine Chests Initiative has been taking shape, the purpose of which is to gain access to ‘failed’ compounds and facilitate their reinvestigation, ideally in clinical experimental studies. Indeed, should it be necessary, resynthesis of interesting compounds is being and could be considered (albeit via. research grants) should an agent no longer be physically available. As these agents have already been administered in patients, toxicological studies are unlikely to be needed, as toxicology reports are included in the Medicines Chest repository.
As Dr Ann Hayes, UK, explained, access to a small number of data packages for candidate agents has already been attained and interest in some of the 9 drugs so far collected is already apparent.
Dr Trevor Robbins, UK, outlined how he has applied for a research grant to investigate whether a D1 receptor antagonist previously developed in Alzheimer’s disease might be used both to further investigate the basic science underlying D1 receptor antagonism and also the effect of this drug on cognition – an area of research in which it has not previously been investigated in clinical patients but one now considered worth of pursuit.
To find out more about the Medicines Chest and the agents available go to https://www.ecnp.eu/projects-initiatives/ECNP-medicines-chest.aspx
What does a pharmaceutical company do with a psychotherapeutic drug once it fails in clinical trials? As often as not, it bins it.
“The real challenge in treating MDD is choosing the right option first time,” said Dr Virginia Soria, Spain, “and making sure that the balance between effect and tolerability works right from the start of therapy.” As she explains, in this way benefit can be gained from the outset and long-term issues such as the worsening or persistence of symptoms can be avoided.
In her experience, the best approach is to treat intensively. Therapies should be tailored to take into the account the severity of the patient’s depression, their age and the type of symptoms being experienced. Achieving a partial response or the persistence of residual symptoms is not the end-point of the treatment, especially in certain subgroups of MDD such as melancholic depression. “We have to get the most out of therapy as early as we can,” she said. And to do this establishing a relationship of trust with the patient is essential. This involves the patient being empowered in the management of the condition and to be a willing participant in their treatment programme.
Dr Soria defines remission in MDD when there are few or no mood symptoms present in a patient as measured using a suitable rating scale. However, while remission is desired, recovery is her ultimate goal – that is a complete, sustained remission with functional restoration in the patient. She estimates that 30-40% of patients attain remission at the first attempt. In those that do not initially remit, further interventions are employed including use of combinations of therapies, augmentation and neuromodulation. Use of ECT can lead to attainment of remission in 70% of those in which it is being used. “Don’t stop treatment after the first attempt,” she said, “If a patient is resistant to antidepressant therapy, re-evaluate them with an open mind and look for the treatment regimen that better suits them.”
Dr Soria believes in the use of a more holistic approach to the management of MDD as it has been reliably demonstrated that psychopharmacology and psychotherapy in combination is more effective in gaining symptom remission than either therapy used alone. Ideally, combination therapy should be used from the outset of treatment. This also includes offering advice on lifestyle management including diet and exercise. “It can often take longer to persuade a patient to exercise than to take their medicine!” she reported.
Currently, Dr Soria evaluates cognitive symptoms in depression mainly in her elderly patients using the Mini-mental state examination or MoCA Montreal scales but, as cognitive symptoms affect global performance and functionality regardless of age, she plans to pay more attention to the assessment of these in future in all patients with depression.
Interview with Dr Virginia Soria, Barcelona