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www.helsinki.fi/yliopisto
Treatment of depression in Finland – why and how?
Erkki Isometsä, 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
01.09.2014
Potential conflict of finterest disclosure: September 2011 – September 2014
• Employment by a pharmaceutical company: (Never)
• Research funding from a pharmaceutical company: (Never)
• Advisory Board or Speakers Bureau Membership: (Never)
• Honoraria for lecturing in educational meetings sponsored by a
pharmaceutical company
o Servier x 2 (2012)
• Honaria for lecturing, other
o Finnish Medical Society Duodecim (2012)
o Finnish Medical Association (2014)
o European College of Neuropsychopharmacology, ECNP (2012)
o Royal College of Psychiatrists (2012)
o Columbia University (2013)
• Funding for participation in scientific meetings from pharmaceutical
companies
o Lundbeck x 1 (2012)
• Licensed psychotherapist (Valvira)
o Income since 1989
1/273 inhabitants in 2013
medicalization ≠ pharmacotherapy
Why should depression be treated?
Depression and associated disability in Finland in 2012
• Increase in disability pensions
ended 2007.
• No. of sick leave periods 26 709 (no.
part-time sick leaves 1980).
• New disability pensions granted due
to depression for 3 549 individuals.
• Total no. of disability pensions for
depression in Finland 36 358.
• Total costs involved > 600 million €.
Honkonen T & Gould R. SLL 44/2011
Cumulative risk of completed suicide among subjects in psychiatric care in
DenmarkCumulative incidence, register-based follow-up to 36y. (median 18y.) since first treatment contact
Nordentoft M et al., Arch Gen Psychiatry 2011;68:1058-1064.
males females
Treatment: The Finnish Current Care Guidelines
Psychotic depression
Depressive episodes and recurrent depression
<1%
4-5%
10-15%
Annual prevalence of depressive syndromes in the general population
mild depressive symptoms
Dg F32-33
Phases of treatment
Acute treatment
Continuation phase
Maintenance phase
6 mo. Recurrent depression (F33)
relapse recurrence
Current Care Guidelines, 2009
Acute treatment of depression
Treatment modality Mild Moderate Severe Psychotic
Psychotherapies + + (+) -
Antidepressants + + + +
Antipsychotics - - - +
Electroconvulsive therapy (ECT)
- - + +
Current Care Guidelines, 2009
Psychotherapeutic treatment
Central forms of psychotherapy in different treament phases
Treatment modality Duration and intensity Evidence in phases of treatment
Acute Continuation and maintenance
Chronic and/or complicated
Cognitive /Cognitive-behavioural (CBT)
A - -
Brief MBCT (8-16x, 1x/wk) - A -
Brief/medium-term CBASP (12-40x)
- - B
Long-term (40-160x, 1-2x/wk)
D D C
Interpersonal (IPT) Brief (12-16x, 1 x/wk) A A -
Psychodynamic Brief (16-25x, 1x/wk) B - -
Long-term (80-240x, 1-3x/wk)
B D B
Current Care Guidelines, 2009
MBCT = mindfulness-based cognitive therapy; CBASP = cognitive behavioral analysis system of psychotherapy
Effectiveness of psychotherapy in depression?
• In the Helsinki Psychotherapy Study (HPS, N=326), patients depression/and or anxiety improved significantly on both brief and long-term psychodynamic as well as solution-focused therapies, but brief therapies were estimated not to be sufficient treatment in the majority of patients.
• In a study (N=341) comparing cognitive-behavioral vs. psychodynamic brief therapies (16 sessions in 22 wks) in outpatients psychiatric care in Amsterdam, proportion of patients remitted 23% in both groups, responders 39% and 37% (Driessen E et al., Am J Psychiatry 2013;170:1041-50.)
• In the UK Improved Access to Psychological Therapies (IAPT) Project, a report of 7859 pts found 55% of patients improved after treatment. However, attrition rate was 47% (Richards & Borglin, J Affect Disord 2011;133:51-60).
Psychotherapy: the issue of capacity
• Overall 5475 licensed psychotherapist aged ≤ 65 y in 31.12.2013
(Valvira).
• In 2009-13, no. of registered new therapists varied annually
between 275-432.
• Of Finnish psychotherapists in 2011,
o ¼ were not currently providing psychotherapy
o 85% provided individual therapy
o Median time devoted to psychotherapeutic work 15h/wk
o Estimated no. of patients treated per year 18 pts./therapist
o Regional distribution uneven, 3-fold differences in density
Rough estimate: 40 -70 000 patients treated/year, in therapies of 1-3 y
Valkonen J et al. Psykoterapeutit Suomessa. Psykoterapiapalvelut ja niiden järjestäminen. KELA, 2011
Pharmacotherapy
• Altogether 444 184 individuals in
2012.
• DDD 69,81 (DDD 70,24 in 2011)
• Change from 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
Finnish Statistics on Medicines, 2012
Sales of antidepressant drugs in Finland in 1990-2012
• Altogether 444 184 individuals in
2012.
• DDD 69,81 (DDD 70,24 in 2011)
• Change from 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
Finnish Statistics on Medicines, 2012
Sales of antidepressant drugs in Finland in 1990-2012
Current Care Guidelines
From: Health Statistics for the Nordic Countries; Nomesko, 2013
Sales of antidepressants in the Nordic countries in 2005-2012
Spontaneous remission
Placebo Antidepressant0%
10%
20%
30%
40%
50%
60%
Typical 6-8 wk antidepressant trial response rates
Spontaneous remission
Placebo Antidepressant0%
10%
20%
30%
40%
50%
60%
Typical 6-8 wk antidepressant trial response rates
The THREAD Study (N=220) : Effectiveness of SSRI-treatment added to supportive treatment in UK primary care
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
Phases of treatment
Acute treatment
Continuation phase
Maintenance phase
6 mo. Recurrent depression (F33)
relapse recurrence
Current Care Guidelines, 2009
NNT 3-6
Conclusions
• Depression is associated with remarkable disability, significant excess mortality, and markedly elevated suicide mortality.
• In mild to moderate depression, there are no significant differences in efficacy or effectiveness between psychotherapies or antidepressants.
• In severe or psychotic depression pharmacotherapy or other biological treatment is usually needed.
• Combined and integrated treatments are needed and most effective.