Measuring success in the treatment of depression: what is most important to patients?

KEYWORDS:

• Depression
• patient-defined outcomes
• treatment
• meta-analysis
• psychotherapy

In the past decades, hundreds of randomized trials have shown that pharmacotherapies, psychotherapies, and several other therapies are effective in the treatment of depression. These trials typically focus on the effects of treatments on depressive symptoms, response, and remission. But when patients seek treatment, is a reduction of depressive symptoms really what they want, or do patients have other goals as well?

This is a highly relevant question, not only because there is a growing recognition of the importance of patient-defined outcomes and the need to involve people with lived experience in research and clinical practice. Another important development is that the diagnostic systems, especially the DSM and ICD, have been increasingly criticized. Depressive disorders are not clear entities with objective tests to establish whether a patient has such a disorder or not. There are also no clear thresholds for when a patient has a disorder and when not. Depression is a highly heterogeneous disorder with many different, widely varying symptom patterns, and high levels of comorbidity with anxiety, substance use, personality, and other mental disorders.

The hundreds of randomized trials examining the effects of treatment have included patients meeting criteria for depressive disorders, and have shown that these treatments have modest, but significant effects on depression. However, if depression is not such a clear entity as the diagnostic systems suggest, but instead a highly heterogeneous mix of many different symptom patterns and other disorders, can we be really sure that we are focusing on the right outcomes? From this perspective, it would be wise to take a step back and have a closer look at what patients need when they seek treatment.

1. Patient-defined outcomes in mental health treatment

There is a long tradition in mental health care focusing on what patients want when they seek treatment. It is not an extensive literature, and it is mostly limited to psychotherapy research, but it goes back to the 1960s and it is illuminating in that it gives indications for what patients really want from treatments [1]. This research shows that patients find symptom reduction a very important goal of therapy, but it is certainly not the only goal. What patients want is very personal and depends on their current situation. Apart from symptom reduction, it is well-known to clinicians that patients want, for example to be able to go back to work, have a more fulfilling life, solve conflicts with partners, other close relatives, friends, want to learn to live with the chronic disorder they recently developed, learn to handle a trauma, recent or in the past.

In this context, the difference between nomothetic and idiographic outcomes is important. Most outcome measures in randomized trials, such as depression measures, are nomothetic, meaning that items of the measure are common to all people in a varying degree. A measure is aimed at locating where a patient scores on this dimension [2]. Idiographic measures, on the other hand, rely on the unique features and views of the patient [3]. When assessing patient-defined goals of treatment, idiographic measures are obviously more relevant.

Over the years several instruments have been developed to systematically assess these idiographic outcomes of treatment. The Target Complaints are the oldest of these measures and goes back to the 1960s [4]. In this approach, the patient describes three target complaints in a clinical interview, and for each of these complaints both the therapist and patient rate how much the problem is bothering the patient. After treatment, both the therapist and patient again rate these problems, but now indicate on a five-point scale how much the problem has improved. There are several other comparable tools, that differ somewhat in approach, specific questions, possible answers, and the timepoint at which they are rated. Examples are the Psychological Outcome Profiles (PSYCHLOPS), the Goal Attainment Scaling, and the Youth Top Problems in the field of child and adolescent mental health treatment [3].

The main approach of these instruments is comparable, meaning that the patient (and sometimes the clinician) indicates what the major problems are, how he or she is affected by them, and how much treatment has helped them. The measures do differ from each other in terms of reliability and validity. However, they all have been found to be very useful in clinical practice, through identifying problems of patients in a standardized way, helping with focusing the treatment, engaging patients in the direction of the treatment, and supporting the evaluation of the success of the therapy.

What the problems are that patients consider important has not been examined extensively, and is mostly limited to small studies in selective patient samples, in widely varying treatment. Unfortunately, this research has not yet been able to give a clear and consistent overview of the most important goals of patients when going into treatment. This research suggests that the goals of patients depend heavily on the stage in their lives and circumstances. One recent study identified several categories of helpful outcomes of psychotherapy, including awareness, insight, and self-understanding, behavioral change, and solution of problems, empowerment, relief, the better understanding of feelings, the reassurance and support from the therapist, and the personal contact with the therapist [5]. Another study was based on in-depth qualitative interviews with patients [6], and found four categories of outcomes which were considered by patients to be the most important: (1) Establishing new ways of relating to others; (2) reduction in symptoms or change in patterns of behavior that used to bring suffering; (3) better self-understanding and insight; and (4) to accept and value oneself.

2. The effects of treatment of depression on quality of life and other outcomes

Although too little research has focused on what patients consider to be the most important goals of treatment and the effects of treatments on these goals, there is a considerable literature showing that treatment of depression not only affects depression, but many other outcomes. In the past years, a considerable number of meta-analyses, especially in the field of psychotherapy, have shown that improvement of depression after depression is significantly associated with outcomes in other domains. In Table 1 an overview of these outcomes is given. This research shows that the treatment of depression also significantly improves the quality of life [7], social functioning [8], anxiety [9], hopelessness [10], dysfunctional thinking [11], and social support [12]. There is a small but interesting set of studies in depressed mothers [13], suggesting that treatment results in improved parental functioning, improved mother–child interactions and the mental health of their children.

Table 1. The effects of psychological treatment for depression on quality of life and other outcomes.

	Nstudies	Effect size	95% CI	Study
Quality of life	31	0.33	0.24 ~ 0.42	Kolovos, 2016
Social functioning	31	0.46	0.32 ~ 0.60	Renner, 2014
Anxiety	52	0.52	0.44 ~ 0.60	Weitz, 2018
Hopelessness	18	1.10	0.72 ~ 1.48	Cuijpers, 2013
Dysfunctional thinking	26	0.50	0.38 ~ 0.62	Cristea, 2015
Social support	15	0.38	0.29 ~ 0.48	Park, 2014
Depressed mothers:				Cuijpers, 2015
• Mental health of their children	7	0.40	0.22 ~ 0.59
• Mother–child interaction	8	0.35	0.17 ~ 0.62
• Parental distress	5	0.67	0.30 ~ 1.04

These meta-analyses find a strong correlation between the effects of treatments on depression and those on the secondary outcomes. Although this cannot be considered as causal evidence, it suggests that successful treatment of depression also has significant effects on these other areas of life. Although patient-defined outcomes have not been examined extensively, this research makes clear that treatment of depression goes beyond effects on depressive symptomatology, and also positively affects other relevant areas of life. These findings should be considered with caution, however, because there are also treatments that have been found to be effective in reducing depression, but without evidence of improving quality of life, such as the use of adjunctive atypical antipsychotics [14].

3. Conclusion

Trials examining treatments of depression have focused mostly on the effects of these treatments on depressive symptomatology, response, and remission. However, patients do not only seek treatment to reduce symptoms. They also go into treatment because of other, more personal goals and targets. It is time that we start recognizing these patient-defined goals more than has been done until now, not only because patients deserve more recognition of their needs, but also because depressive disorders are not the clearly defined entities as our diagnostic systems suggest. In order to understand depressive disorders and their treatment better, we have to take a broader perspective, and take the patient perspective into consideration in our research. That will probably not be a dramatic shift in our thinking about outcomes, because there is quite some evidence that many treatments not only have effects on depression, but also on many other secondary outcomes. This is not confirmed for all treatments, however. But it does mean that we should step away from uni-dimensional research focusing on symptoms of depression only, that instead we should also listen better to the needs of patients and include their needs and views into outcome research.

Declaration of interest

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants, or patents received or pending, or royalties.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper is not funded.