Selected Health Conditions and Likelihood of Improvement with Treatment (2020) / Chapter Skim
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4 Mental Health Disorders
4 Mental Health Disorders
Pages 149-232
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From page 149... ...
The decision on which specific mental health disorders to include was based on the prevalence of the disorders in the United States and on their potential responsiveness to treatment. The committee selected the mental disorders listed in Table 4-1, recognizing that others might also meet its criteria.
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The DSM-5 (APA, 2013) provides the professionally accepted diagnostic criteria for mental health disorders used by health care professionals in the United States and was the source for the diagnostic criteria described in this chapter.
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Response to Treatments for Mental Health Disorders in the Context of Disability Most of the mental disorders under consideration can occasionally result in SSA-defined disability. Individuals meeting the criteria for disability are likely to have a severe form of the disorder or a significant comorbidity that affects response to treatment and the potential for remission.
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From page 152... ...
For the mental health conditions described in this chapter, the discontinuity between symptoms and functioning as well as the multiple, inter-related domains that measure function are not well understood. The 2019 National Academies report Functional Assessment for Adults with Disabilities found that when assessing the functional abilities of individuals with mental health disorders, the following domains are important: general cognitive/intellectual ability, language and communication, learning and
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Mental Health Conditions and Pain It is well known that mental conditions and chronic pain often occur together, but the causal pathway or direction of the association is still debated. Chronic pain may contribute to mental conditions, and, vice versa, mental conditions may result in an increased risk of chronic pain (Velly and Mohit, 2018)
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. MAJOR DEPRESSIVE DISORDER The adult depressive disorders listed in the DSM-5 have common features, such as sad, empty, or irritable mood, and they include major depressive disorder (MDD)
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. Professionally Accepted Diagnostic Criteria for Major Depressive Disorder The DSM-5 describes MDD as involving discrete episodes of at least 2 weeks' duration involving clear-cut changes in affect, cognition, and neurovegetative functions and inter-episode remissions (i.e., when the symptom severity is within the normal, nondepressed range)
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D The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
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Relapse is the reemergence of symptoms of major depression following some level of remission, but preceding recovery. Recovery is a prolonged period of remission that marks the end of the index episode (e.g., 6–12 months)
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Some medical conditions with high rates of comorbid depression include cancer, cardiovascular disease, multiple sclerosis, traumatic brain injury, HIV, epilepsy, migraines, Parkinson's disease, hepatitis C, and chronic pain. Standard Measures of Outcomes for Major Depressive Disorder The field still lacks reliable and valid biomarkers for depression, recovery, and prognosis.
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Treatments for Major Depressive Disorder Depression treatment can be divided into two phases. The goal of the acute phase, which typically lasts 8–12 weeks, is to achieve symptom remission.
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Department of Defense Clinical Practice Guideline for the Management of Major Depressive Disorder provide evidence-based recommendations that have been peer reviewed. The committee assumes those guidelines are applicable to the civilian population.
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Finally, a recent systematic review and network meta-analysis3 of the comparative efficacy and tolerability of pharmacologic and somatic 3Network meta-analyses use all available data from randomized clinical trials to estimate the effect of each intervention relative to other interventions, even those that have not been compared directly.
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Length of Time to Improvement for Major Depressive Disorder Estimating time to symptom improvement is complicated by numerous factors, including under-treatment, the need for multiple sequential treatment episodes to achieve remission of symptoms, treatment-resistance
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Finally, there appears to be the potential for depression improvement among adults of any age. A recent systematic review of predictors of antidepressant efficacy reported that antidepressants are effective across a broad age range and that any age effects were inconsistent and depended on the type of treatment (Perlman et al., 2019)
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, although the factors that cause impairment have not been clearly specified. Professionally Accepted Diagnostic Criteria for Bipolar Disorders Bipolar disorder can be experienced in various forms and is typically accompanied by serious impairments in work and social functioning.
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There is a great variability in the presentation, sequence, and length of episodes in bipolar disorders, but patterns are repeated for a given patient. For example, some patients tend to experience a manic episode followed by a depressive episode, whereas the reverse pattern is typical for other patients.
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or to another medical condition. Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy)
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. Note: A full hypomanic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy)
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Standard Measures of Outcomes for Bipolar Disorder A recent systematic review examined the clinical utility of patientreported and clinician-rated measures of mania and depression for the management of bipolar disorder (Cerimele et al., 2019)
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Correspondingly, a few tools have been developed and used to measure the functional outcomes of bipolar disorder. Some of the most widely used tools were developed for the general measurement of function (e.g., the Global Assessment of Functioning, Functioning Assessment Short Test, and WHODAS 2.0, which is directly linked to the International Classification of Functioning, Disability and Health)
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For clarity and efficiency, only first- and second-line treatments for mania are listed in Table 4-6. Bipolar disorders cause a wide range of functional impairments that can be lasting and merit treatment in an effort to improve overall outcomes.
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Clinical support refers to the application of expert opinion of the CANMAT committees to ensure that evidencesupported interventions are feasible and relevant to clinical practice. Therefore, treatments with higher levels of evidence may be downgraded to lower lines of treatment due to clinical issues such as side effects or safety profile.
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172 SELECTED HEALTH CONDITIONS AND LIKELIHOOD OF IMPROVEMENT TABLE 4-6 Pharmacologic Treatments for Acute Mania: Level of Evidencea and Line of Treatmentb Level of Evidence and Line of Treatment by Phase Acute Maintenance Acute Prevention of Acute Any Mood Prevention of Prevention of Acute Mania Episode Depression Mania Depression First-line treatments: Monotherapies Lithium Level 1 Level 1 Level 1 Level 1 Level 2 Quetiapine Level 1 Level 1 Level 1 Level 1 Level 1 Divalproex Level 1 Level 1 Level 3 Level 2 Level 2 Asenapine Level 1 Level 2 Level 2 Level 2 nd Aripiprazole Level 1 Level 2 Level 2 nd Negative evidence Paliperidone Level 1 Level 2 Level 2 nd nd Risperidone Level 1 Level 4 Level 4 nd nd Cariprazine Level 1 nd nd nd Level 1 First-line treatments: Combination therapies Quetiapine + Li/ Level 1 Level 1 Level 1 Level 1 Level 4 DVP Aripiprazole + Level 2 Level 2 Level 2 nd Level 4 Li/DVP Risperidone + Li/ Level 1 Level 4 Level 4 nd Level 4 DVP Asenapine + Li/ Level 3 Level 4 Level 4 nd Level 4 DVP Second-line treatments Olanzapine Level 1 Level 1 Level 1 Level 1 Level 1 Carbamazepine Level 1 Level 2 Level 2 Level 2 Level 3 Olanzapine + Li/ Level 1 Level 4 Level 4 Level 4 nd DVP Li + DVP Level 3 Level 3 Level 3 nd nd Ziprasidone Level 1 Level 4 Level 4 nd Negative evidence
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Clinical support refers to application of expert opinion of the CANMAT committees to ensure that evidencesupported interventions are feasible and relevant to clinical practice. Therefore, treatments with higher levels of evidence may be downgraded to lower lines of treatment because of clinical issues such as side effects or safety profile.
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. Length of Time to Improvement for Bipolar Disorders The committee could not find any evidence to indicate clearly what the time to functional improvement in bipolar disorders is.
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The disability and reduced quality of life associated with a diagnosis of OCD is substantial. WHO has ranked OCD as the 10th leading cause of disability of all health conditions in the industrialized world.
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In DSMIV, OCD was considered in the class of anxiety disorders. In DSM-5 it was considered in the class of obsessive compulsive and related disorders.
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; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder)
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. Treatments for Obsessive Compulsive Disorder To the extent that the Y-BOCS, which covers both symptom severity and functioning, has been used in studies on which the practice guidelines are based, the treatments should have implications for both symptom reduction and functioning.
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. Although the APA guidelines recommend ERP as a first-line treatment, the Canadian Clinical Practice Guidelines for Management of Anxiety, Post Traumatic Stress, and Obsessive Compulsive Disorders suggest that
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2013 guidelines indicate that more people have clinical remission with group CBT rather than with sertraline medication. If patients are non-responsive to CBT, it is recommended that SSRIs or CBT plus SSRIs be used (Janardhan Reddy, 2017)
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. However, the Canadian clinical practice guidelines suggest that it may be helpful for improving comorbid depressive symptoms (Katzman et al., 2014)
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. Length of Time to Improvement for Obsessive Compulsive Disorder According to the Canadian clinical practice guidelines, the optimal duration and intensity of treatment is a persistent question (Katzman et al., 2014)
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The benefits of ERP may be more durable than those of some SRIs after discontinuation, but it is also possible that the observed differences in relapse rates across the two treatment types could be explained by other factors. Relationship Between Symptomatic and Functional Improvement in Obsessive Compulsive Disorder As previously mentioned, the treatment for OCD very likely improves functional outcomes based on improvements in the Y-BOCS.
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POSTTRAUMATIC STRESS DISORDER PTSD is a potentially chronic and disabling condition associated with significant morbidity and mortality as well as with disruptions in family, work, and social relationships (APA, 2013)
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Until more is known about the implications of the change in diagnostic criteria on PTSD screening, diagnosis, and treatment, this report must be read and interpreted with appropriate caution. Developmental Course, Gender Distribution, and Comorbidities According to the National Comorbidity Survey, the lifetime prevalence of PTSD in the U.S.
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186 SELECTED HEALTH CONDITIONS AND LIKELIHOOD OF IMPROVEMENT TABLE 4-8 DSM-5 Criteria for Posttraumatic Stress Disorder Criterion/Symptom Description Note: The following criteria apply to adults, adolescents, and children older than 6 years.
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or another medical condition. Specify whether: With dissociative symptoms: The individual's symptoms meet the criteria for posttraumatic stress disorder and, in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following: 1.
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. According to the APA publication Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder in Adults (2017)
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. Standard Measures of Outcomes for Posttraumatic Stress Disorder In almost all studies of PTSD treatment, the main outcome of interest is PTSD symptom reduction (other secondary outcomes typically assessed include the loss of the PTSD diagnosis or improvement in functioning)
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Psychotherapy for Posttraumatic Stress Disorder According to the VA/DoD joint document Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder, the first-line recommendation for PTSD is psychotherapy with treatments that involve cognitive restructuring or exposure (as compared with non-trauma-focused psychotherapy or pharmacotherapy)
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From page 191... ...
. The VA/DoD guideline is generally consistent with the ISTSS Posttraumatic Stress Disorder Prevention and Treatment Guidelines, which strongly recommends CBT, cognitive therapy, EMDR, PE, and trauma-focused CBT (Hoskins et al., 2015)
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. Length of Time to Improvement for Posttraumatic Stress Disorder People with PTSD may face functional deficits related to education, socioeconomic status, social relationships, and employment (APA, 2017)
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Social Anxiety Disorder Professionally Accepted Diagnostic Criteria for Social Anxiety Disorder SAD, also known as social phobia, is a mental disorder characterized by excessive and persistent fears of scrutiny, embarrassment, and humiliation in social or performance situations, leading to significant distress
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Compared with the DSM-IV, Text Revision (TR) , changes to the diagnostic criteria for SAD have been minimal.
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I The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
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. Persons with medical conditions that include highly visible symptoms, such as tremulousness from Parkinson's disease, stuttering, facial disfigurement, and hyperhidrosis, may develop excessive social anxiety and meet DSM-5 criteria for SAD (Schneier et al., 2001)
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. Psychotherapy for Social Anxiety Disorder CBT developed for SAD is the best studied and most efficacious of the psychotherapies (Canton et al., 2012; Katzman et al., 2014)
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. Medications for Social Anxiety Disorder Table 4-10 lists recommendations for pharmacotherapy for SAD from the 2014 Canadian clinical practice guidelines (Katzman et al., 2014)
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Systematic reviews and a network metaanalysis confirmed that the classes of drugs that include SSRIs and SNRIs have a greater effect on outcomes than placebo (Mayo-Wilson et al., 2014)
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Specific domains of functioning may be included as secondary outcomes, but functional outcomes are not reviewed or summarized in clinical treatment guidelines, systematic reviews, and meta-analyses of treatments for SAD. Furthermore, most studies assess only short-term outcomes and do not provide information on the durability of the treatment effects.
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. PD is also more prevalent in individuals with medical conditions, including thyroid disease, hypoglycemia, seizure disorders, chronic pain, and cardiac conditions, among others (APA, 2010; Katzman et al., 2014)
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D The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder)
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Treatments for Panic Disorder Clinical practice guidelines indicate that PD can be effectively treated with psychotherapy, medications (usually antidepressants) , or a combination of the two (Andrews et al., 2018; APA, 2009; Katzman et al., 2014; NICE, 2011)
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Psychotherapy for Panic Disorder Among the psychosocial treatments for PD, CBT is most extensively supported by research. While there is no high-quality, unequivocal evidence to support one psychologic therapy over the others for the treatment of PD with or without agoraphobia, a 2016 network meta-analysis concluded that CBT is often superior to other psychotherapies (Pompoli et al., 2016)
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. Medications for Panic Disorder Table 4-12 lists recommendations for pharmacotherapy for PD from the 2014 Canadian clinical practice guidelines (Katzman et al., 2014)
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Length of Time to Improvement for Panic Disorder CBT PD protocols usually involve 12–14 weekly sessions and sometimes include booster sessions following treatment. However, briefer treatment courses and compressing the duration of therapy by administering multiple sessions per week have also been shown to be effective (Katzman et al., 2014)
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Relatedly, shorter duration of panic, but not of agoraphobia, predicts greater improvement post treatment. Generalized Anxiety Disorder Professionally Accepted Diagnostic Criteria for Generalized Anxiety Disorder GAD refers to excessive anxiety and worry for more days than not regarding multiple events or activities and lasting for at least 6 months.
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, contamination or other obsessions in obsessive compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder)
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Treatments for Generalized Anxiety Disorder Clinical practice guidelines indicate that GAD can be effectively treated with psychotherapy or medications (usually antidepressants) (Andrews et al., 2018; Baldwin et al., 2014; Katzman et al., 2014; NICE, 2011)
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. Medications for Generalized Anxiety Disorder Table 4-14 lists recommendations for pharmacotherapy for GAD as presented in the Canadian clinical practice guidelines (Katzman et al.,
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, aerobic exercise, acupuncture, more data are needed meditation, and yoga-based treatments aFirst-line treatment recommendations derived from Levels 1 and 2 evidence plus clinical support for efficacy and safety. bSecond-line treatment recommendations derived from Level 3 evidence or higher plus clini cal support for efficacy and safety.
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Furthermore, because the relationship between anxiety disorder symptoms and functioning appears to be weak, one cannot draw conclusions about functioning based on information about symptom improvement. A systematic review of the relationship between symptoms and functioning in individuals with common anxiety disorders found a modest overall relationship (McKnight et al., 2016)
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Professionally accepted diagnostic criteria for these conditions are detailed in the DSM-5. People diagnosed with a mental health disorder are directed to a specific treatment depending on clinical practice guidelines for treatment, their treatment history, their treatment preference, and treatment availability, among other factors.
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Any estimates of time to improvement needs to consider the fact that clinical trials generally exclude participants with comorbidities. Fifth, the mental health disorders discussed in the report are under-recognized and effective treatments, particularly evidence-based psychotherapies, are often unavailable.
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Even after treatment response or remission from an anxiety disorder, individuals may continue to have significant functional impairments, which in turn may predispose them to a relapse of the anxiety disorder. The committee notes that all of those conditions may be associated with chronic pain, which may contribute to increased risk for mental health disorders, and mental health disorders may result in an increased risk of chronic pain.
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From page 216... ...
2018. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder, and generalised anxiety disorder.
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2012. Guidelines for the pharmacologic treatment of anxiety disorders, obsessive–compulsive disorder, and posttraumatic stress disorder in primary care.
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2010. High occur rence of mood and anxiety disorders among older adults: The National Comorbidity Survey Replication.
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2014. Rapid cycling in bipolar disorder: A systematic review.
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2015. Psychosocial functioning and health-related quality of life associated with posttraumatic stress disorder in male and female Iraq and Afghanistan war veterans: The valor registry.
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2018. Psychologic and pharmacologic treatments for adults with posttraumatic stress disorder: A systematic review update.
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2007. Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans.
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2015. Pharmacotherapy for post-trau matic stress disorder: Systematic review and meta-analysis.
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2014. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive– compulsive disorders.
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2005. Generalized anxiety disorder in late life: Lifetime course and comorbidity with major depressive disorder.
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2014. Remission from post-traumatic stress disorder in adults: A systematic review and meta-analysis of long term outcome studies.
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2011. Prevalence and axis I comorbidity of full and partial posttraumatic stress disorder in the United States: Results from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions.
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2017. Verbal flu ency in bipolar disorders: A systematic review and meta-analysis.
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2015. The state of personalized treatment for anxiety disorders: A systematic review of treatment moderators.
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2017. Re storing function in major depressive disorder: A systematic review.
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2017. Early improvement as a resilience signal predicting later remission to antidepressant treatment in patients with major depressive disorder: Systematic review and meta-analysis.
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. Cochrane Database of Systematic Reviews 2017(10)
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