EFFECTS OF COMBINED

PHARMACOTHERAPY AND PHYSICOTHERAPY FOR IMPROVING WORK FUNCTIONING IN MAYOR DEPRESIVE DISORDER.

Chandra kurniawan Sindya wasundari

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Johan budiman Kadek Sinthia

Yuddy Fiyanthi
Winda Dwiastuti

I. BACKGROUND
Major depressive disorder is a leading cause of work-related disability and lost work productivity.

First-line recommended treatments for major depressive disorder include antidepressants and cognitivebehavioural therapy (CBT).

The research will combining telephone-delivered CBT with an antidepressant would improve symptom and work productivity outcomes compared with an antidepressant alone.
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II. AIMS

To examine symptom-based and work functioning outcomes with combined pharmacotherapy and psychotherapy treatment of major depressive disorder.

III. METHOD

Employed patients with a DSM-IV diagnosis of major depressive disorder were treated with escitalopram 1020 mg/day for the entire 12 weeks and randomised to :

telephone-administered cognitivebehavioural therapy (telephone CBT) (n = 48)

adherence-reminder telephone calls (n = 51).

Outcomes included the MontgomeryAsberg Depression Rating Scale (MADRS), administered by masked evaluators via telephone,and self-rated work functioning scales completed online

A.

PARTICIPANTS

Participant were recrited from clinic referrals and by advertising at 3 side ( Vancouver, Calgary dan Toronto).
Exclusion Criteria
Off work on short- or long- ability Pregnant of lactating Serious suicidal risk Unstable medical conditions diganose of OMD, substance misuse/dependence. Use of antidepresant or psychotropic drugs within 7 days of baseline visit. Treatment-resistance in current episode. Previous use of escitalprolam or CBT for depression. Use any additional treatment for depression 5 during study.

Inclusion Criteria
and out-patients aged 1965 years old diagnosis of major depressive disorder by DSM-IV criteria Current paid employment of 15h/week MADRS score : 19 or higher Competency to give information

B. OUTCOME ASSESSMENTS
Change in the MADRS score from baseline to endpoint. a. Response : if 50% improvement in MADRS scores to end-point. b. Remission : if end-point MADRS 12

C. PROCEDURES

Screening + Informed Consent Make schedule for five study visits (baseline, 2, 4, 8 and 12 weeks) to patient. Monitored medications and documend adverese event (by psychiatrists). Rated the patient using the MADRS over the telephone by trained independent evaluators, and masked to treatment assignment and adverse event (by structure interview guide) within 2 days of each study visit. Give patient an email with a link tonansecure internet website to complete the study quistionares. : 99 evaluable participant : 86 participant eleminated because adverese events

Number of Participant End Participant

All comparison were analysed using ANCOVA.

D.

STUDY TREATMENTS

1. Medication
2. Escitalopram, dose starting with 10mg/ day and increasing to 20 mg/day. CBT Used a telephone-administrated CBT program (30-40 min instead of 60 min per session). Eight telephone CBT session were schedule over 8-10 weeks. Initial session occured within 2 weeks of randomisations Focused on motivation enhancement excercises. Subsequent sessions occured weekly Focused in identify, challenging and distancing from negative thoughts. Final sessions Focused on a personal care plan and self management skills. Control Condition A 10-minute structured telephone call weekly, with enquiry about progress and reminders to take medication properly.
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IV. RESULTS
a. Clinical Outcome There was no significant difference between the telephone-CBT and escitalopram-alone groups, with only small observed effect size (d=0.16).

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b. Work Function Outcome The work functioning scale did show significant differences between treatment conditionts. In the LOCF analysis, the telephone-CBT group had a significantly greater improvement than the escitalopram-alone group (p=0.046). Unfortunately, from baseline to end-point, the escitalopramalone group had numerically higher reduction in hours of work missed than the telephone-CBT group.

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V.

DISCUSSION

The main results showed that adjunctive telephoneadministered CBT in combination with escitalopram did not result in differences in symptom-based clinical outcomes compared with escitalopram alone; however, the combination treatment did result in superior improvement in some aspects of work productivity, as assessed by instruments designed to assess productivity change.

Telephone-administered psychotherapy has been shown in meta-analyses to be more effective than treatment-as-usual conditions in reducing symptoms of depression

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CONT DISCUSSION

In this study, telephone CBT was well accepted by patients, with 79% of participants rating themselves as satisfied or highly satisfied with the therapy

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VI. LIMITATION
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The sample size of this study may have limited power to detect smaller effect sizes in clinical and functional outcomes Work functioning and productivity was measured only with self-rating scales the participants were not masked to treatment condition and the control condition consisted of adherence reminder telephone calls that were more brief than the telephone CBT sessions, so we cannot exclude the possibility that attention, patient expectations or other non-specific factors led to superior work outcomes with telephone CBT

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The telephone-delivered CBT used in this study was a brief (eight, 30-minute sessions) intervention designed for use in primary care settings

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CONCLUSION

Combinaed treatment with escitalopram and telephone administered CBT significantly improved some self-reported work functioning outcomes, but not symptom-based outcomes, compared with escitalopram alone.

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CRITICAL APPRAISAL AN ARTICLE ON THERAPY

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