Setting treatment goals for real life

Setting treatment goals for patients with depression is complicated by a number of factors. These include the clinical heterogeneity of the condition;1,2 misperceptions of what it encompasses (making key symptoms easy to miss, either because the patient didn’t consider them relevant to mention, or the HCP didn’t probe into the details of their daily life);3 and the nuanced, highly subjective nature of symptoms.1-3

The CANMAT guidelines for treatment of depression summarise the goals for the acute and maintenance treatment phases with two clinical questions: “How do you get people with depression well?” and “How do you keep them well?”3 Both questions are essential in the long term, since achieving remission of all individual symptoms in the acute phase is key to enabling full functional recovery and reducing risk of relapse.3 The key, CANMAT notes, is to engage the patient as a partner for developing treatment goals.3

“The overall goals of treatment of major depressive disorder should focus on alleviating functional impairments and improving quality of life in addition to achieving symptom resolution and episode remission” – American Psychiatric Association

Each patient’s personal experience of depression defines what they perceive as progress. While clinical scales can be a useful measure in the acute phase, in the long term it may be more relevant to keep track of patients’ progress towards functional improvement in their own lives. In a recent social media campaign on our patient platform, Rethink Depression, we put questions around this to the community, such as “If you could wish for a victory, what would it be?” and “If I have a good day tomorrow, the first thing I would do is _____”. The responses demonstrated the variation of how symptoms manifest themselves in daily life, across work, home and social functioning:

  • “Wash my face, do my hair, have a healthy breakfast and go for a walk and do a bit of exercise”
  • “Go to the gym”
  • “Take a run”
  • “Dance”
  • “I would hug someone I love”
  • “Get all my tasks of that day done”
  • “Be excited for something”
  • “Sleep all night”
  • “Finish my readings”
  • “Make (and eat) my own food”

Since patients may not bring up these difficulties in a consultation, it requires initiative from the clinician to uncover them.1 The APA guidelines encourage questioning patients (in addition to observation and collateral history whenever possible) around how their activities and enjoyment of life have been altered by their symptoms.1 This allows the clinician to help the patient in translating vague goals (e.g., “I have difficulty meeting commitments”) into specific targets appropriate to his or her impairments (“What would you need to do to be able to meet your work and family obligations?”).4 These goals rarely change long-term, but may be replaced if another goal becomes more relevant.4 In this way, the patient becomes engaged as an active participant in their recovery, and is provided with added motivation to achieve and maintain their treatment goals.4

References
  1. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder. Third Edition. 2010.
  2. Greer TL et al. CNS Durgs 2010; 24(4): 276–284.
  3. Lam RW et al. Can J Psychiatry 2016; 61(9): 510–523.
  4. Battle CL et al. J Psychiatr Pract. 2010; 16(6): 425–430.
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