Treatment of depression in Finland – why and how?

1. 01.09.2014 Treatment of depression in Finland – why and how? ErkkiIsometsä, Dr.Med.Sci., Professor of Psychiatry, Department of Psychiatry, University of Helsinki; Chief physician (part-time), Department of Psychiatry, Helsinki University Central Hospital (HUCH); Research Professor (part-time) , National Institute for Health and Welfare, Helsinki

2. Potentialconflict of finterestdisclosure: September 2011 – September 2014 • Employmentby a pharmaceuticalcompany: (Never) • Researchfundingfrom a pharmaceuticalcompany: (Never) • Advisory Board orSpeakers Bureau Membership: (Never) • Honoraria for lecturing in educationalmeetingssponsoredby a pharmaceuticalcompany • Servier x 2 (2012) • Honaria for lecturing, other • FinnishMedicalSociety Duodecim (2012) • FinnishMedical Association (2014) • European College of Neuropsychopharmacology, ECNP (2012) • Royal College of Psychiatrists (2012) • Columbia University (2013) • Funding for participation in scientificmeetingsfrompharmaceuticalcompanies • Lundbeck x 1 (2012) • Licensedpsychotherapist (Valvira) • Incomesince 1989

3. 1/273 inhabitants in 2013

4. medicalization ≠ pharmacotherapy

5. Whyshould depression betreated?

7. Depression and associateddisability in Finland in 2012 • Increase in disabilitypensionsended2007. • No. of sickleaveperiods26 709 (no. part-timesickleaves 1980). • New disabilitypensionsgranteddue to depression for 3 549 individuals. • Total no. of disabilitypensions for depression in Finland 36 358. • Total costsinvolved > 600 million€. Honkonen T & Gould R. SLL 44/2011

9. Cumulativerisk of completedsuicideamongsubjectsin psychiatriccare in Denmark Cumulativeincidence, register-basedfollow-up to 36y. (median 18y.) sincefirsttreatmentcontact males females Nordentoft M et al., ArchGenPsychiatry 2011;68:1058-1064.

10. Treatment: The FinnishCurrentCareGuidelines

11. Annualprevalence of depressivesyndromes in the general population <1% Psychotic depression 4-5% Depressiveepisodes and recurrent depression Dg F32-33 10-15% milddepressivesymptoms

12. Phases of treatment CurrentCareGuidelines, 2009 6 mo. Recurrent depression (F33) recurrence relapse Acutetreatment Continuationphase Maintenancephase

13. Acutetreatment of depression CurrentCareGuidelines, 2009

15. Psychotherapeutictreatment

16. Central forms of psychotherapy in differenttreamentphases CurrentCareGuidelines, 2009 MBCT = mindfulness-basedcognitivetherapy; CBASP = cognitivebehavioralanalysissystem of psychotherapy

18. Effectiveness of psychotherapy in depression? • In the Helsinki PsychotherapyStudy (HPS, N=326), patients depression/and oranxietyimprovedsignificantly on bothbrief and long-termpsychodynamic as well as solution-focusedtherapies, butbrieftherapieswereestimatednot to besufficienttreatment in themajority of patients. • In a study (N=341) comparingcognitive-behavioral vs. psychodynamicbrieftherapies (16 sessions in 22 wks) in outpatientspsychiatriccare in Amsterdam, proportion of patientsremitted 23% in bothgroups, responders 39% and 37% (Driessen E et al., Am J Psychiatry 2013;170:1041-50.) • In the UK ImprovedAccess to PsychologicalTherapies (IAPT) Project, a report of 7859 ptsfound 55% of patientsimprovedaftertreatment. However, attritionratewas 47% (Richards & Borglin, J AffectDisord 2011;133:51-60).

19. Psychotherapy: theissue of capacity • Overall 5475 licensedpsychotherapistaged ≤ 65 y in 31.12.2013 (Valvira). • In 2009-13, no. of registerednewtherapistsvariedannuallybetween 275-432. • Of Finnishpsychotherapists in 2011, • ¼ werenotcurrentlyprovidingpsychotherapy • 85% providedindividualtherapy • Median timedevoted to psychotherapeuticwork 15h/wk • Estimated no. of patientstreated per year 18 pts./therapist • Regionaldistributionuneven, 3-fold differences in density • Roughestimate: 40 -70 000 patientstreated/year, in therapies of 1-3 y Valkonen J et al. Psykoterapeutit Suomessa. Psykoterapiapalvelut ja niiden järjestäminen. KELA, 2011

20. Pharmacotherapy

21. Sales of antidepressantdrugs in Finland in 1990-2012 • Altogether 444 184 individuals in 2012. • DDD 69,81 (DDD 70,24 in 2011) • Changefrom the year 2011: -1%. • Likely causes of increase: • Increased treatment-seeking and provision for depression, particularly in primary health care • New treatment indications • Continuation/maintenance treatment FinnishStatistics on Medicines, 2012

22. Sales of antidepressantdrugs in Finland in 1990-2012 • Altogether 444 184 individuals in 2012. • DDD 69,81 (DDD 70,24 in 2011) • Changefrom the year 2011: -1%. • Likely causes of increase: • Increased treatment-seeking and provision for depression, particularly in primary health care • New treatment indications • Continuation/maintenance treatment CurrentCareGuidelines FinnishStatistics on Medicines, 2012

23. Sales of antidepressants in the Nordiccountries in 2005-2012 From: Health Statistics for the NordicCountries;Nomesko, 2013

25. Typical6-8 wkantidepressant trial responserates

26. Typical6-8 wkantidepressant trial responserates

27. The THREAD Study (N=220) : Effectiveness of SSRI-treatmentadded to supportivetreatment in UK primarycare Remission by 12 wks: 42% vs. 24%, NNT = 6 (95% l.v. 4-26) Kendrick T et al. Health Technology Assessment 2009;13:22. DOI:10.3310/htaI 3220

28. Phases of treatment CurrentCareGuidelines, 2009 6 mo. Recurrent depression (F33) recurrence relapse NNT 3-6 Acutetreatment Continuationphase Maintenancephase

30. Conclusions • Depression is associatedwithremarkabledisability, significantexcessmortality, and markedlyelevatedsuicidemortality. • In mild to moderate depression, thereare no significantdifferences in efficacyoreffectivenessbetweenpsychotherapiesorantidepressants. • In severeorpsychotic depression pharmacotherapyorotherbiologicaltreatment is usuallyneeded. • Combined and integratedtreatmentsareneeded and mosteffective.