Alkem

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Retrospective Evaluation of Safety and Effectiveness Outcomes in the Use of fixed dose combination of Dextromethorphan-Bupropion in Indian Major Depressive Disorder Patients (RESPONSE Study)

BASIC DETAILS

Patient code (Do not write name here) *

Date *

Demographics

Patient's Age *

Gender*

Male Female Other

Weight (kg) *

Clinical Characteristics

Duration of MDD (months) *

History of Antidepressant Treatments *

Yes No

Comorbid Conditions

Anxiety *

Yes No

Substance abuse *

Yes No

Chronic pain *

Yes No

HTN *

Yes No

Diabetes *

Yes No

Sleep disturbances *

Yes No

Eating disorders *

Yes No

Treatment Data (Dextromethorphan + Bupropion for minimum 3 months)

Were adjunctive therapies used?*

Yes No

Please Specify

Drug	Dose	Frequency

MADRS Score at Week 1 *

MADRS Score at Week 2 *

MADRS Score at Week 4 *

MADRS Score at Week 8 *

MADRS Score at Week 12 *

Improvement in Anhedonia *

Yes No

Physician's global assessment *

Excellent Good Average Poor

Safety & Tolerability Outcomes

Treatment well tolerated *

Yes No

Adverse Event *

Yes No

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