Healthy Skepticism Library item: 6339

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Publication type: news

For depression relief, try variety of medications Study: Antidepressants help most patients if they sample several kinds
MSNBC 2006 Nov 1
http://www.msnbc.msn.com/id/15503920/from/ET/

Notes:

Stuart Jones’ Comments:

Dr Nelson got it wrong…. In placebo-controlled clinical trials depressed patients treated with placebo achieved 80% of a perceived beneficial antidepressant drug effect.

And what exactly should we be “wanting more” of? STAR*D was an unmitigated disaster as a drug trial study. The drop out rate for all reasons including side-effects was phenomenal.
The study’s patient inclusion criteria predicated the use of polypharmacy — a dubious, and some claim, dangerous practise — and certainly a process that makes it extremely difficult for pharmacologists to discover which drug caused what side-effect(s).

Dr. Thomas Insel, director of the National Institute of Mental Health, said that because there was no comparison group of people who got no treatment, [or a placebo] it is hard to know how many of those got better on their own, with enough passage of time, or because of the drugs.

So why the NIMH provided $35 million for this shambles is a mystery, but maybe that’s what Dr Nelson’s — “A Four-Course Meal That Leaves Us Wanting More” refers to? — The study certainly didn’t warrant the spin put on it by the media.
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Also see — (http://www.ahrp.org/cms/content/view/374/28/ )
Separating the Facts from the Propaganda_Latest Findings of Depression Study — The board of the AHRP slated this study.
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Extracts from an Editorial by J. Craig Nelson, M.D.
The STAR*D Study:
A Four-Course Meal That Leaves Us Wanting More (http://ajp.psychiatryonline.org/cgi/content/full/163/11/1864)
Although psychotic and bipolar patients were excluded, most other psychiatric disorders were allowed. Most clinical trials in depression exclude patients with recent active substance abuse. STAR*D only excluded patients likely to need inpatient detoxification.
This study was not placebo controlled, and it is not possible to determine what portion of response was associated with nonspecific factors (which would tend to obscure true drug differences).

Full text:

The final stage of a landmark federal study on treating depression suggests
that two-thirds of sufferers eventually can be helped if they are patient
enough to keep trying medications until they find one that works.
Thirteen percent of the 123 study participants who did not get better on the
first three drugs they tried were helped by a fourth, researchers found.

But there is a downside to so many attempts: The more tries people made, the
more likely it was that they later would relapse and slide back into
depression.
“It’s a sobering message when you get down to requiring three or four
steps,” said the chief researcher, Dr. A. John Rush of the University of
Texas Southwestern Medical Center in Dallas. “It says that follow-up is
critical” to make sure that people stay on the drugs, he said.

Results were published Wednesday in the November issue of the American
Journal of Psychiatry.

About 15 million Americans each year suffer depression, the nation’s top
mental health problem. Drugs to treat the disorder have had only limited
testing until now. The government launched the six-year, $35 million study
to test a variety of these medications in “real world” settings – people
seeking help at community clinics and doctor’s offices.

Multiple treatment attempts
The project started out with 3,671 adults diagnosed with major depression.
Half of them had a family history of it, and more than half had suffered
multiple bouts of it themselves.
All were started on Celexa, made by Forest Laboratories and one of a widely
used class of drugs called SSRIs. Nearly 37 percent had their depression go
into remission after this first try. The rest switched to another
antidepressant or continued with Celexa and added a second treatment. This
second step helped 31 percent of that group.

The third and fourth attempts brought success rates of 14 percent and 13
percent, respectively. When all results from these various groups of
participants were looked at collectively, 67 percent of the total group had
been helped by one or more drugs.

However, 40 percent of those who achieved remission on their first drug
relapsed within a year. That rose to 55 percent of those who took two tries
to succeed and 65 percent and 70 percent of those requiring three and four
tries, respectively. “More steps are still worthwhile, but you have a
decreasing return,” Rush said.

Dr. Thomas Insel, director of the National Institute of Mental Health, said
that because there was no comparison group of people who got no treatment,
it is hard to know how many of those got better on their own, with enough
passage of time, or because of the drugs.
“I think the overall results are hopeful,” he said. “The problem with
depression is that people and their families feel hopeless. The message here
is that medication can be helpful.”

Why did one-third of people not get better with any drugs? Possible
explanations include genetic or biological differences, and life
circumstances or other medical conditions that interfered with treatment.
Medications may have been started too late to do any good, and some forms of
depression may not respond to drugs.

Doctors say that 14 weeks is enough time for a drug to have a chance to
work. After that, people should consider trying something else or adding a
second treatment.
Soon to be published are separate results on the effectiveness of
counseling, which some participants got in the second stage of the study.

Diagnosing depression: (Source: National Institute of Mental Health)
Depression is a serious medical illness that comes in many forms with a
variety of symptoms.
If you have any of the following symptoms for a prolonged period, it may be
time to seek help.
Persistant sad or anxious mood
Feelings of hopelessness or pessimism
Feelings of guilt or worthlessness
Loss of interest in hobbies or activities
Fatigue or decreased energy
Difficulty concentrating or making decisions
Insomnia or oversleeping
Changes in appetite or weight
Thoughts of death or suicide
Restlessness or irritability
Headaches or chronic pain

C 2006 The Associated Press. All rights reserved.

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