Case outcome: use of outcome measures

The IDS and the QIDS are two public domain rating scales (www.ids-qids.org) for depression. They were used in this particular case

There are many other depression rating scales available, such as the Beck Depression Inventory, the Zung Depression Self Rating Scale, etc., that may also be utilized. The PHQ-9 (Patient Health Questionnaire, www.ncbi.nim.nih.gov/pubmed/11556941) is likely the most widely used in clinical practice and in primary care practice

Routine use of rating scales in psychopharmacological practice may be similar to a PCP always measuring weight and blood pressure in each patient. It is even more similar to the routine use of blood glucose, renal, or blood pressure monitoring techniques in the diabetic patient

In this TRD scenario, the clinician is acutely aware if the patient is better, worse, or the same at each visit. The clinician can also predict pending worsening or relapse of symptoms, or medication noncompliance based on ratings outcomes at each visit. As the patient enters the office after completing the ratings, the clinician has about 30 symptom data points already apparent before any questioning starts in the session. Theoretically, before the patient enters the psychopharmacologist’s office, it is known what percent the patient is better or worse. This actually frees up clinician time to further investigate social stressors, maladaptive personality symptoms, or provide better education and informed consent. Interestingly, use of rating scales may make you a better therapist.

An abnormal value on these types of routine outcome measures likely triggers a reaction from the clinician to re-evaluate the patient and consider more aggressive treatment in order to obtain a better remission of symptoms

In the case of diabetes, this may decrease comorbidities, improve social functioning, and decrease healthcare utilization rates. In terms of MDD, rating scales likely orient the clinician that the patient, indeed, is not in remission, thus triggering more comprehensive and more aggressive care with regard to psychotherapy, medication management, and collaboration with other providers and family members. The end result likely is improved outcomes over the long term

Finally, there are many public domain, short, and simple rating scales that may be utilized for each psychiatric disorder whether it is PD, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), BN, AUD. Many of these could be simply incorporated into practice as a PCP might incorporate the taking of the blood pressure

Rating scales:

• – Can save clinicians time if automated

• – May allow a clinician to stay within APA guidelines

• – May allow better detection of comorbidities and residual symptoms

• – May create pivotal treatment decision points as if these were abnormal laboratory values that require action

• – May free up more session time to address non-pharmacologic issues

Posttest self-assessment question and answer

Which of the following may cause abnormal movement disorders?

A. Duloxetine

B. Mixed amphetamine salts

C. Aripiprazole

D. Lamotrigine

E. B and C

F. All of the above

Answer: F

Duloxetine is associated with intention tremor. Mixed amphetamine salts are associated with intention tremor and tics. Aripiprazole is associated with resting tremor, akathisia, dystonia, and dyskinetic movements. Lamotrigine is associated with intention tremor, dysmetria, dysarthria, and ataxia.

References

1.Stahl SM. Stahl’s Essential Psychopharmacology, 4th edn. New York, NY: Cambridge University Press, 2013.

2.Stahl SM. Stahl’s Essential Psychopharmacology: The Prescriber’s Guide, 4th edn. New York, NY: Cambridge University Press, 2011.

3.American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder, 3rd edn. Washington, DC: American Psychiatric Association Press, 2010.

4.American Psychiatric Association. Handbook of Psychiatric Measures, 2nd edn, Rush JA Jr., First MB, Blacker D, eds. Washington, DC: American Psychiatric Publishing, 2008.

5.Inventory of Depressive Symptomatology (IDS) and Quick Inventory of Depressive Symptomatology (QIDS). http://www.ids-qids.org. Accessed November 2014.

6.Schwartz TL, Stahl SM. Treatment strategies for dosing the second generation antipsychotics. CNS Neurosci Ther 2011; 17:110–17.

7.Zimmerman M, McGlinchey JB, Chelminski I. Measurement-based care and outcome measures: implications for practice. In: Schwartz TL, Petersen T, eds. Depression: Treatment Strategies and Management, 2nd edn. NewYork, NY: Informa, 2009; Ch. 6.

8.Topel M, Zajecka J, Goldstein C, Siddiqui U, Schwartz TL. Using what we have: combining medications to achieve remission. Clin Neuropsychiatry 2011; 8:4–27.

9.Zimmerman M, Chelminski I, Young D, Dalrymple K. Using outcome measures to promote better outcomes. Clin Neuropsychiatry 2011; 8:28–36.

10.Guy W. ECDEU Assessment Manual for Psychopharmacology: Revised (DHEW publication number ADM 76–338). Rockville, MD: US Department of Health, Education and Welfare, Public Health Service, Alcohol, Drug Abuse and Mental Health Administration, NIMH Psychopharmacology Research Branch, Division of Extramural Research Programs, 1976; pp. 534–7.

11.Stahl SM, Mignon L. Stahl’s Illustrated Antipsychotics: Treating Psychosis, Mania and Depression, 2nd edn. New York, NY: Cambridge University Press, 2010.

12.Ishibashi T, Horisawa T, Tokuda K, et al. Pharmacological profile of lurasidone, a novel antipsychotic agent with potent 5-hydroxytryptamine 7 (5-HT7) and 5-HT1A receptor activity. Pharmacol Exp Ther 2010; 334:171–81.

13.Citrome L. Iloperidone, asenapine, and lurasidone: a brief overview of 3 new second-generation antipsychotics. Postgrad Med 2011; 123:153–62.

Patient file

The Case:

The lady with major depressive disorder who bought an RV.

The Question:

What is a therapeutic dose and duration for vagus nerve stimulation therapy in depression?

The Psychopharmacological dilemma:

Finding an effective treatment for chronic treatment-resistant or refractory depression while managing a severely ill patient

Pretest self-assessment question (answer at the end of the case)

Which of the following is not an invasive surgical treatment for resistant depression?

A. TMS

B. VNS

C. ECT

D. DBS

E. EpCS

F. A and C

G. B and D

H. All of the above