West London NHS Trust

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Retrospective Analysis using Discover data set to quantify the state of the overall North West London population with a recorded diagnosis of depression in terms of demographics and NHS services resource usage with focus on Treatment Resistant Depression.

Little systematic attention has been directed toward the subject of treatment-resistant depression. Although these patients constitute a distinct minority, their treatment consumes a major portion of the clinician's time and significant resources. Several major factors concerning treatment-resistant depression appear evident: (1) although there is an emerging consensus of what constitutes "adequate" treatment, the majority of patients receive suboptimal drug regimens; (2) misdiagnosis of depression subtypes can lead to suboptimal treatment and "pseudo-resistance" to drug therapy; (3) treatment strategies for resistant depression should use systematic algorithms to avoid confusion and limit "therapeutic nihilism" in the patient and physician; and (4) the patient's risk/benefit ratio for each successive treatment application must be considered with the potential benefit weighed against the increasing risk of illness morbidity Treatment-resistant depression (TRD) is a growing area of discussion among researchers and medical professionals. Varying resistance levels among patients with TRD pose difficulties in determining an effective treatment for individual patients. Currently, there is only one treatment option specifically for TRD approved by the EMA. The current treatment recommendations include restructured oral therapy regimens and psychotherapy. The alternative of continuous switching and/or combining of antidepressants requires extensive patient education and counselling on proper administration and potential side effects. The use of guidelines and individual patient response are key factors in finding an optimal treatment approach and effectively managing TRD (Managing Treatment-Resistant-Depression, Priyam K. Mithawala, PharmD, BCPS; Daijah M. Davis, PharmD Candidate 2022 US Pharmacist. 2020;45(5):15-20). NICE guidelines set out the standard treatment for depression includes antidepressants or psychological therapies (including cognitive behavioural therapies) or a combination of both. In severe depression when multiple treatments have failed, electroconvulsive therapy or other forms of neurostimulation are sometimes used. Some patients with treatment resistant depression have tried up to 12 antidepressants and waited 10 years before they are seen at specialist centres. The figures fall far short of targets set out in draft guidance from the National Institute for Health and Care Excellence, which says that all patients who have not responded to two antidepressants should be referred to specialists. NICE estimates that 2.7 million people in the UK will suffer from depression and be resistant to available treatment. As stated by Allan Young from the Maudsley in a BMJ article in 2018 https://www.bmj.com/content/363/bmj.k5354 “there is no capacity in secondary mental health team to deal with this. So, what are the GPs supposed to do?” It is therefore important to understand more about the impact of Treatment Resistant Depression (TRD) on the population of North West London. TRD in NWL compared with the national predefined standards for quality of care in TRD will inform subsequent action plans to improve care. This study represents an important step of a clinical practice improvement journey, aiming at first to describe the current practice in the management of TRD and related costs, then to be followed by the identification of the priority areas to address and define strategies to improve quality of care and more efficient resource use in TRD.

15/04/2021

TRE