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Depression

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B33CNS Course Assignment What is the economic impact of depression in adults in the United Kingdom and how should medicines be used to reduce that economic impact? According to World Health Organization (WHO), depression is the second most common cause of disability in the world and it will be the biggest health burden out of all wellbeing issues on society both economically and sociologically within 20 years [1]. This statement is indeed disheartening but what actually is depression that it will have such a great impact? Depression refers to a state of low mood and presence of negative affect which is usually associated with a range of emotional, cognitive, physical and behavioral symptoms
[2]

.

These include two core symptoms as in persistent depressed mood plus loss of interest in most activities and several other symptoms such as significant weight change due to increased or reduced appetite, sleeping disorder, psychomotor agitation, fatigue, reduced ability to think or concentrate, feelings of worthlessness, guilt or inappropriate grief as well as recurrent thought of death or suicide. There is no definite cause of depression but some risk factors which can trigger depression have been identified. First, one’s family history of mental disorder. American Psychiatric Association expresses that if one identical twin is diagnosed with depression, the other twin has a 70% chance of getting the same problem
[3]

. Next, females are more susceptible to

get depression compared to males. In the UK, annual prevalence of depression is estimated to be 21/1000 for people aged 16-65 in which females are about 25/1000 while males are about 17/1000. Besides, an episode of major depression which requires treatment happens in about 1 in 4 women and 1 in 10 men at some point of their life. In addition, females who are pregnant or in post-natal period and housewives have a greater chance of getting depression. Chronic medical illnesses such as cancer, heart disease and pain can also trigger depression as well as previous history of depression. Studies have shown that about 50% of those who had depression will develop it again [4]. Psychological factors such as low self-esteem and overwhelmed by stress can also increase the risk of getting depression. Although

depression can happen in all ages, elderlies are however have a higher risk especially those in care homes. Findings suggested there is about 2 in 5 people in care homes suffered from depression [5]. Depression can cause a large decrement in health state and severe destruction to patients’ lives. Depression can impact the brain, heart and other parts of the body [6]. Studies have shown that long term depression can cause damage to the cardiovascular system as a result of inappropriate release of adrenaline. Besides, depression can aggravate pain due to the physical diseases such as migraines and arthritis. Depression will also cause aches with no apparent source. According to Harvard Medical School, depression makes pain harder to treat as it may cause patients to withdraw from rehabilitation programmes
[7]

. In addition,

many people with depression turn to substance abuse to relieve their symptoms instead of seeking proper medical help [8]. Substance abuse can lead to alcoholism and drug addiction which may result in liver damage, kidney damage and even death due to overdosing. Hence, not surprisingly, depression can increase mortality. As stated by Centers for Disease Control and Prevention, people with untreated depression may die up to 25 years earlier than the average lifespan [9]. Due to these effects of depression on health, patients’ work functioning can also be affected. A study done by Beck et al. found that severity of depression is proportional to the productivity loss
[10]

. Moreover, depression often causes social withdrawal and patients

would eventually experience difficulty with their interpersonal relationships. All of these result in a poor quality of life. The effect of depression on health and quality of life is often evaluated using health-related quality of life (HRQoL) measurements. EQ-5D [11] and 15D
[12]

as summarized below are two well established and generic HRQoL instruments.

Table 1 Health-related Quality of Life measurements: EQ-5D and 15D HRQoL measurements Dimensions 5 Dimensions: Mobility, 15 Dimensions: hearing, eating, Mobility, breathing, speech, EQ-5D 15D

self-care, usual activities, vision, pain or discomfort, anxiety sleeping, or depression

elimination, usual activities, mental function, discomfort and symptoms, depression, distress, vitality, sexual activity.

Valuation

3 grades of severity for each dimension EQ visual analogue scale (EQ VAS) on vas as ‘Best imaginable health state’ or Worst imaginable health state’ 5 grades of severity for each

Rate personal health state dimension.

Completion time Administration method

5-15 minutes Mainly self-administration

5-15 minutes Mainly self-administration

In addition to evaluate patients’ HRQoL, HRQoL measurements allow estimation of health utilities loss and calculate quality adjusted life years (QALY). As mentioned earlier, depression would be the biggest health burden within 20 years and this enormous burden would be borne by both healthcare system and the society. In 2000, a UK study [13] estimated the total cost of depression in adults to be more than £ billion in 9 which both direct and indirect costs are involved. Besides, intangible costs which has no monetary value such as effect of depression on quality of life, pain and suffering of patients as well as family members have also been studied. Direct treatment costs are as primary

and secondary care costs while indirect costs are caused by morbidity (loss of working days) and mortality (loss of life years). Direct treatment costs that borne by the National Health Service (NHS) are estimated to be £ million. In which, only a minor proportion 370 is accounted for antidepressants and the rest are for in patient and out-patient care as well as general practitioner consultations. However, this estimation is believed to be an underestimation as the costs for counseling and psychotherapy such as cognitive behaviour therapy are not included due to lack of reliable data. In terms of indirect cost, there is about 90% accounted for morbidity costs where 107.9 billion of lost working days are related to depression. Morbidity costs are borne by both the society i.e. the employers and government as depression will affect one’s ability to work and reduce productivity. Moreover, employers are able to make sickness benefit claims from government if employee has been absent for 5 days. There is also a significant amount of mortality costs as 2507 out of 3583 suicide cases and 108 out of 3583 death due to drugs poisoning in 2000 are related to depression. The loss of future lifetime earnings due to depression are estimated to be £ 562 million. In total, indirect cost of depression is more than £ billion which is about nine-tenth of the total cost. 8 There are various types of antidepressants as in tricyclic antidepressants (TCA), monoamine oxidase inhibitors (MAOIs), serotonin specific reuptake inhibitors (SSRIs), serotonin/norepinephrine reuptake inhibitors (SNRIs) and atypical antidepressants. According to NICE guidelines, generic SSRIs are the first line treatment for depression due to their favourable benefit-risk profile even though there is no significant difference in efficacy [14]. However, recent researches have suggested that escitalopram (allosteric SSRI), venlafaxine (SNRI) and mirtazapine are more effective. In 2008, Wade et al. have used Sheehan Disability Scale (SDS) as the primary outcome measure to compare the cost-effectiveness of escitalopram and duloxetine [15]. Healthcare resources and sick leaves were also evaluated in the study. Over the study period of 24 weeks, escitalopram has resulted in 54% of reduction in sick leave duration and lowered the costs by 49% as compared to duloxetine. This shows that escitalopram is more costeffective than duloxetine. This result is supported by Armstrong et al. where they used quality adjusted life weeks (QALW) as an outcome measure [16]. In the study, mean QALW

was 41.0 for escitalopram and 38.2 for duloxetine. Moreover, the mean annual cost for escitalopram was $726 lower than that of duloxetine. In terms of venlafaxine, a study carried out by Lenox-Smith et al. has shown a greater costeffectiveness when compared to fluoxetine (SSRI) and amitriptyline (TCA)
[17]

. The

treatment cost for venlafaxine, fluoxetine and amitriptyline were £ 1530, £ 1539 and £ 1558 respectively. This study assessed QALY as outcome measure. QALYs gained for patients treated with venlafaxine were 0.0022 more than fluoxetine and 0.0035 more than amitriptyline. As compared to escitalopram, venlafaxine showed a lower cost-effectiveness in a study by Nordstrom et al. [18]. They measured the effectiveness outcome using QALY as well. 0.00865 QALYs were expected to gain for patients treated with escitalopram compared to patients receiving venlafaxine. These studies suggested that venlafaxine is dominating generic SSRIs and TCA while surmounted by escitalopram. Borghi and Guest have collected the studies from 1997 to 1999 to compare cost effectiveness of mirtazapine with amitriptyline and fluoxetine in the treatment of moderate and severe depression in the UK
[19]

. Benefit of the treatments was measured by the

proportion of successfully treated patients. This study suggested that mirtazapine is more cost-effective as it increased the proportion of successfully treated patients by 4% when compared to amitriptyline and 3.5% when compared to fluoxetine. In a meta-analyses done by Cipriani et al., cost-effectiveness of mirtazapine appears to be the greatest due to highest number of QALYs gained and lowest costs [20]. The results are summarized in Table 2. Table 2 Mean cost and QALYs associated with each antidepressant. Antidepressant Mean QALYs per person Moderate depression Mirtazapine Escitalopram Venlafaxine Duloxetine Fluoxetine 0.620 0.616 0.615 0.596 0.595 Severe Depression 0.468 0.463 0.462 0.439 0.438 Mean cost per person (£ ) Moderate Depression 1459 1597 1781 1831 1561 Severe Depression 1781 1918 2102 2148 1878

Although mirtazapine is the most cost-effective, SSRIs still remain the first choice of antidepressants due to their excellent risk-benefit profile as mentioned above. However, management of depression should not be solely dependent on guidelines but a patientcentered care should be prioritized. NICE stepped-care model suggested that antidepressants should only be given if initial interventions including support, active monitoring, life style changes and low-intensity psychological interventions have failed
[14]

. This means antidepressants are generally not

recommended in mild depression but should be offered for patients with persisted symptoms and patients diagnosed with moderate as well as severe depression. However, before commencing antidepressants, patients should be screened for past medical history, past treatment experiences and most importantly, suicidal thoughts as these may affect the choices and treatment period. For instance, a maximum of one week treatment is given for those with high suicidal risk. Patients should also be informed with the gradual development of antidepressants effect, period of treatment, potential adverse reactions as well as withdrawal effects before initiating the treatment. These ensure understanding of patients and improve patients’ adherence hence treatment outcome. After treatment initiation, patients should be monitored for about 3-4 weeks to assess treatment efficacy. If the treatment is effective, patients should continue treatment for at least 6 months after remission of symptoms. On the other hand, if the first treatment has failed, patients should be given another SSRI or mirtazapine as second line. They should also be monitored for another 3-4 weeks to assess drug efficacy. It is possible that some patients will not get any effect from antidepressants and the condition is known as resistant depression. In resistant depression, augmentation therapy which involves an augmentation agent such as lithium in addition to existing antidepressant is used.

Depression

Mild-moderate

Active monitoring, Life style advices, Low-intensity psychological interventions

1st Line: SSRIs

Moderate-Severe

2nd Line: Another SSRI or mirtazapine

3rd Line: Mirtazapine or SNRI inhibitors or tricyclic antidepressants. Augmentation therapy if severe.

Diagram 1 Treatment plan for depression A study indicated there is about 50% of depressive patients stopped their antidepressants without seeking professional advice
[21]

. This seems to be a huge problem as it does not

only affecting the quality use of antidepressants but also deteriorating their personal wellbeing hence causing further costs. Pharmacists are in a unique position to ensure optimal, safe and effective use of antidepressants. First of all, pharmacists are responsible to notify any medication related problem as in patients’ suitability, interactions and adverse effects to the prescribers. Besides, pharmacists can also provide a better alternate for the prescriber if there is a need. Patients’ non-adherence are generally due to lack of understanding of the medicines, fear of the side effects and not knowing the importance of completing treatment. Therefore, pharmacists should provide excellent and effective counselling to ensure optimal use of antidepressants. For instance, majority of patients think that antidepressants are mood-altering drugs and can cause addiction. Hence, it is pharmacists’ responsibility to clarify these misconceptions and provide key educational messages about antidepressants such as duration of treatment and delayed action of antidepressants to patients.

Since pharmacists meet patients on a regular basis, monitoring patents condition, treatment efficacy and adverse effects are also pharmacists’ obligation [22]. By doing so, pharmacists can resolve any non-adherence issues, patients’ concerns in addition to maintain a good relationship with patients. Pharmacists are also responsible to serve patient as a whole. Hence, despite solving medication related problem, pharmacists have to also provide social support for the patients. This can be reached by counselling patients’ family members nevertheless patients’ consent is needed. During the consultation, pharmacists can provide information for them on depression as well as the management. This has been proved to improve patients’ adherence as well as the treatment outcome. Last but not least, pharmacists should overcome own barriers such as lack of time as well as education about mental health issues to optimize the use of antidepressants and perform professionally in the management of depression.

(2021 words)

References 1. News.bbc.co.uk, (2014). BBC NEWS | Health | Depression looms as global crisis. [online] Available at: http://news.bbc.co.uk/1/hi/8230549.stm [Accessed 14 Nov. 2014].

2. Patient.co.uk, (2014). Depression and Anxiety. Information and depression symptoms | Patient.co.uk. [online] Available at: http://www.patient.co.uk/doctor/depression-pro [Accessed 14 Nov. 2014].

3. Healthline.com,(2014). Depression Risk Factors. [online] Available at: http://www.healthline.com/health/depression/risk-factors#Overview1 [Accessed 14 Nov. 2014].

4. Mentalhealth.org.uk, (2014). Depression. [online] Available at: http://www.mentalhealth.org.uk/help-information/mental-health-a-z/D/depression/ [Accessed 14 Nov. 2014].

5. Mentalhealth.org.uk, (2014). Mental Health Statistics: Older People. [online] Available at: http://www.mentalhealth.org.uk/help-information/mental-health-

statistics/older-people/ [Accessed 14 Nov. 2014].

6. Tracy, N. (2014). Effects of Depression: Physical, Social Effects of Depression. [online] Healthy Place. Available at: http://www.healthyplace.com/depression/effects/effects-ofdepression-physical-social-effects-of-depression/ [Accessed 6 Nov. 2014].

7. Health.harvard.edu, (2014). Depression and pain - Harvard Health Publications. [online] Available at: http://www.health.harvard.edu/newsweek/Depression_and_pain.htm

[Accessed 6 Nov. 2014].

8. LIVESTRONG.COM, (2010). Long-Term Effects of Untreated Depression | LIVESTRONG.COM. [online] Available at: http://www.livestrong.com/article/69705longterm-effects-untreated-depression/ [Accessed 9 Nov. 2014].

9. Cdc.gov, (2014). CDC - Depression - Data and Statistics - Mental Health. [online] Available at: http://www.cdc.gov/mentalhealth/data_stats/depression.htm [Accessed 11 Nov. 2014].

10. Beck, A., Crain, A., Solberg, L., Unutzer, J., Glasgow, R., Maciosek, M. and Whitebird, R. (2011). Severity of Depression and Magnitude of Productivity Loss. The Annals of Family Medicine, 9(4), pp.305-311.

11. Euroqol.org, (2014). EuroQol - Home. [online] Available at: http://www.euroqol.org/ [Accessed 12 Nov. 2014].

12. 15d-instrument.net, (2014). 15D instruments. [online] Available at: http://www.15dinstrument.net/15d [Accessed 12 Nov. 2014].

13. Thomas, C. (2003). Cost of depression among adults in England in 2000. The British Journal of Psychiatry, 183(6), pp.514-519.

14. National Institute for Health and Clinical Excellence, (2009). Depression in Adults. [online] Available at: https://www.nice.org.uk/guidance/cg90/resources/guidance-

depression-in-adults-pdf [Accessed 8 Nov 2014]

15. Wade, A., Gembert, K. and Florea, I. (2008). Comparative study of the efficacy of acute and continuation treatment with Escitalopram versus Duloxetine in patients with major depressive disorder. European Psychiatry, 23, p.S268.

16. Armstrong, E., Malone, D. and Haim Erder, M. (2008). A Markov cost-utility analysis of escitalopram and duloxetine for the treatment of major depressive disorder*. Curr Med Res Opin, 24(4), pp.1115-1121.

17. Lenox-Smith, A., Greenstreet, L., Burslem, K. and Knight, C. (2009). Cost Effectiveness of Venlafaxine Compared with Generic Fluoxetine or Generic Amitriptyline in Major Depressive Disorder in the UK. Clinical Drug Investigation, 29(3), pp.173-184.

18. Nordströ G., Danchenko, N., Despiegel, N. and Marteau, F. (2012). Costm, Effectiveness Evaluation in Sweden of Escitalopram Compared with Venlafaxine Extended-Release as First-Line Treatment in Major Depressive Disorder. Value in Health, 15(2), pp.231-239.

19. Borghi J, Guest JF: Economic impact of using mirtazapine compared to amitriptyline and fluoxetine in the treatment of moderate and severe depression in the UK. Eur Psychiatry 2000, 15(6):378-387.

20. Cipriani, A., Furukawa, T., Salanti, G., Geddes, J., Higgins, J., Churchill, R., Watanabe, N., Nakagawa, A., Omori, I., McGuire, H., Tansella, M. and Barbui, C. (2009). Comparative efficacy and acceptability of 12 new-generation antidepressants: a multipletreatments meta-analysis. The Lancet, 373(9665), pp.746-758.

21. PAMPALLONA, S. (2002). Patient adherence in the treatment of depression. The British Journal of Psychiatry, 180(2), pp.104-109.

22. Chong, W., Aslani, P. and Chen, T. (2013). Adherence to antidepressant medications: an evaluation of community pharmacists' counseling practice. Dove Press, [online] 2013(7), pp.813-825. Available at: http://www.dovepress.com/getfile.php?fileID=17222 [Accessed 11 Nov. 2014].

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...Depression Tanajia Jones Pd2 What is depression? Depression is a state of being depressed (sad, gloomy, dejected, downcast) a state of general emotion dejection and withdrawal, sadness greater and more prolonged than that warranted by any objective reason. (dictionary.com) What causes depression? There is no specific cause for depression, major roles that play in depression includes genetics, environment, life events, medical conditions, and the way people react to events that happen in their life. Many researchers discovered that depression runs in families and many can inherit genes that make it more likely for them to get depressed. Tragic life events can trigger depression; it can be as simple as moving, changing schools and can become as big as a death in the family a friend, family member, or a pet. Sometimes this can cause you to go beyond normal grief and cause depression. Depression is also found in young adults starting around the time they hit age thirteen, for most teens, a negative, stressful, or unhappy family atmosphere can affect their self-esteem and lead to depression. This can also include poverty, homelessness, violence in the family, relationships && community. Medical conditions are also a factor in causing depression; some medications can affect hormone balance which can cause an effect on the mood. For some teens undiagnosed learning disabilities can block success, hormonal changes might affect the mood. What occurs...

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The Depression

...reach broader layers of the public. The rise of social unrest during the Depression heightened the political concerns of artistic works, while New Deal programs gave artists both federal recognition and the funding and space to work out new cultural forms. Technical changes, like the popularization of the radio, changed how accessible culture was and to whom, and an international break from formalism and modernism also worked to produce a popularized, socially conscious tendency in American art. During the Depression decade, Washington State, often seen as marginal to national art history, hosted some of the most innovative theatre, musical, and performing arts work in the nation, with sometimes global resonance. It is one of the ironies of the Great Depression that the emblematic cultural institution of Washington State, the Seattle Art Museum, was created and privately funded during the darkest days of the economic crisis, when tens of thousands were losing jobs and homes. SAM was a gift to the city from art collector Richard Fuller and his wealthy mother Margaret Fuller. In 1931, they hired UW architect Richard Gould to design a museum sited in Volunteer Park and pledged much of their personal art collection to the city. The building, which now houses the Seattle Asian Art Museum, opened to the public in 1933. The SAM story reminds us that not everyone suffered or even lost money during the Depression and reminds us too that philanthropy accelerated in the 1930s, as some...

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Premium Essay

Depression

.... The Great Depression was a period of unprecedented decline in economic activity. It is generally agreed to have occurred between 1929 and 1939. Although parts of the economy had begun to recover by 1936, high unemployment persisted until the Second World War. Background To Great Depression: * The 1920s witnessed an economic boom in the US (typified by Ford Motor cars, which made a car within the grasp of ordinary workers for the first time). Industrial output expanded very rapidly.  * Sales were often promoted through buying on credit. However, by early 1929, the steam had gone out of the economy and output was beginning to fall. * The stock market had boomed to record levels. Price to earning ratios were above historical averages. * The US Agricultural sector had been in recession for many more years * The UK economy had been experiencing deflation and high unemployment for much of the 1920s. This was mainly due to the cost of the first world war and attempting to rejoin the Gold standard at a pre world war 1 rate. This meant Sterling was overvalued causing lower exports and slower growth. The US tried to help the UK stay in the gold standard. That meant inflating the US economy, which contributed to the credit boom of the 1920s. Causes of Great Depression Stock Market Crash of October 1929 During September and October a few firms posted disappointing results causing share prices to fall. On October 28th (Black Monday), the decline in prices turned...

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