# First antidepressant fails 70% of the time, great article



## Dreamer (Aug 9, 2004)

This is why someone like me w/a mood disorder w/DP/DR has been experimenting around for so long. Finally it's not my frickin' fault.

I find this research very positive though. We have to encourage more real-world communication between doctors and patients. I'm sick of being sold a bill of goods over and over and over.

The word is getting out. Take Heart. :shock: 8)

http://dailynews.att.net/cgi-bin/health?e=pri&dt=060105&cat=news&st=news112381&src=webmd

*First Antidepressant Fails 70% of Time
Updated 1/5/2006 6:07:29 PM

By Daniel DeNoon

Jan. 4, 2006 - Antidepressant medication, all by itself, puts 
depression into remission for 30% of patients, a government-funded 
study shows.

What about the other 70% of people with depression? And how long 
must the lucky 30% stay on medication? Stay tuned. The study is 
just starting to get interesting.*

Unlike nearly every other study of antidepressant medications, this 
one is funded by the National Institute of Mental Health (NIMH) -- 
not by the drug industry. It doesn't just measure small 
improvements in carefully selected people with depression. This 
study looks at real patients seeking help from real-world 
psychiatrists and primary-care doctors. And it plans to continue 
until nearly every patient fully recovers from depression.

*"We have to increase our expectations from depression 
treatments," study co-leader Madhukar H. Trivedi, MD, tells WebMD. 
"We have to push for full remission as an outcome, because falling 
short leads to less quality of life, with worsening of symptoms 
over time."*

The first results from the 4,000-patient study -- the STAR*D 
(Sequenced Treatment Alternatives to Relieve Depression) study -- 
appear in the January issue of the American Journal of Psychiatry.
NIMH Director Thomas R. Insel, MD, hails STAR*D as a landmark for 
depression research.

*"Too many research studies have little immediate relevance to 
practice, and too little practice is based on research evidence," 
Insel writes in an editorial accompanying the study. "STAR*D [is] 
studying patients in real-world settings and asking questions with 
practical relevance."*

*Married Patients Get Better Faster*

In this first report, Trivedi and colleagues report on some 3,000 
patients who completed the first phase of the study. All patients 
first get 12 weeks of treatment with Celexa, an SSRI 
antidepressant.

Why Celexa? Trivedi says it's not because they think Celexa is more 
effective than other antidepressants. The researchers chose to 
start with Celexa because SSRI antidepressants are the first choice 
of most U.S. doctors and because of Celexa's chemistry. The drug 
stays in the body long enough to avoid withdrawal symptoms if a 
patient misses a few doses, but it goes away fast enough so that 
its effects won't be confused with those of the next drug doctors 
may try.

In fact, Trivedi says, he thinks the results seen with Celexa 
should apply to other modern antidepressant drugs.

*Overall, about 30% of patients got full remission with Celexa 
treatment. But it didn't happen overnight. Nearly all patients 
needed at least eight weeks of treatment -- and a relatively high 
dose of Celexa -- before they got better.

"We find there is a time point in the first few weeks of depression 
treatment when doctors and patients lose patience and the patient 
drops out of treatment. The drop-out rate is huge," Trivedi says. 
"But if you go on long enough, remission rates are higher. You may 
need more doctor visits than people generally have when getting 
treated for their depression."*

*The patients who got better tended to be white, female, 
better educated, with higher pay, and married. Being married seemed 
to be particularly helpful.*

"Being in a marital relationship seems to produce better outcomes," 
Trivedi says. "It is hard to separate out better marital status 
from other factors such as being in a better socioeconomic group. 
But the finding is very interesting. It sounds like a meaningful 
marital relationship makes depression treatment work better."

Why?

"Maybe it is because the spouse offers the patient support," 
Trivedi suggests. "Maybe the spouse is encouraging the patient to 
stay with the treatment. Maybe the spouse is identifying things for 
the patient that the patient brought back to us and that let us 
tailor that individual's treatment much better. And there is the 
potential that these positive relationships may make the stressors 
in the patients' day-to-day lives a little shorter."

*First Antidepressant Fails 70%*

Because the patients are being seen in busy psychiatric clinics or 
primary-care centers, STAR*D patients first get antidepressant 
medication without psychotherapy. That may be part of the 
explanation for the 70% failure rate, says depression expert Andrew 
Elmore, PhD, a private-practice psychotherapist and assistant 
clinical professor at Mt. Sinai School of Medicine in New York.

"If you are running a race, you need food and training. Most people 
need drugs and therapy to treat their depression," Elmore tells 
WebMD. "In all the studies, the group that gets both goal-oriented 
psychotherapy and an effective drug does better than the group that 
gets either one alone."

But the bigger question, Insel notes, is what treatment do those 
70% of depressed patients need now?

*Finding Out What It Takes to Beat Depression*

There's no answer to Insel's question -- today. That may change 
this summer, when findings from the second part of the STAR*D trial 
will be announced.

Part two of the study is much more complicated. Patients who don't 
get full remission of their depression will be offered the chance 
to switch to one or more different antidepressant drugs, add a new 
antidepressant drug, or switch to psychotherapy (with or without 
drug treatment).

"If you get to full remission with the first medication, you are 
better off because you don't have to go to the expense and time of 
trying more things," Trivedi says. "For those who don't get full 
remission, it is the same thing as with diabetes and arthritis and 
hypertension and other things -- you keep looking for something 
that works. But for those who finally get full remission, I think 
there is a profound payoff. Your symptoms are all gone, and you 
return to your previous level of function, and your long-term 
outcome is profoundly better than if you didn't get to remission."

When patients do get full remission, they enter a 12-month 
follow-up period. During this time, drug treatment continues.
Elmore argues that while these patients are getting successful 
treatment, it's too soon to say they are in full remission.

*"Is it remission when they still have to take a drug?" Elmore 
asks. "My epilepsy is under control when I take phenobarbital every 
day. But if I still need the drug, my epilepsy is not in 
remission."*

But Elmore praises the STAR*D trial for providing desperately 
needed real-world information. And whether it's called remission or 
successful treatment, Trivedi notes that patients badly need to get 
their depression under control.

*"If patient symptoms have reduced to levels where they are 
virtually gone, that is remission," he says. "There may be some 
minor symptoms left, but their functioning is the same as you and 
I. And if you do achieve remission, your longer-term outcome is 
better than if we stop treatment before remission. A person not in 
remission is three times more likely to have a relapse in three to 
nine months."*

*Measuring Depression*

*Trivedi says one of the most important parts of the STAR*D trial 
is that all patients get evaluated for depression symptoms at every 
doctor visit.*

"If you have high blood pressure, and nobody measures your blood 
pressure, how would you know to do anything different if your 
medication isn't working?" Trivedi says. "You have to measure 
symptoms on a regular basis. Patients can do this themselves. I 
personally would say psychotherapy patients should measure, too. 
Any treatment that actually is likely to be used for depression, we 
should regularly be measuring patient symptoms."

Doctors who aren't trained in psychotherapy may need to measure.

But Elmore says trained therapists are capable of more 
sophisticated evaluations than multiple-choice questionnaires can 
provide.

*"We measure progress by getting to know a patient well enough to 
know whether that person's situation has improved," he says. "I 
would think that the judicious therapist measures patient progress 
via means far more robust than paper-and-pencil tests. Therapy is 
not just giving advice. It is trying to understand whether the 
advice is helping the patient, and making the patient comfortable 
enough to know whether the therapy is helping or not. This can be 
done without subjecting a patient to a written exam."*

------------------------------------------------------------------

*SOURCES: Trivedi, M.H. American Journal of Psychiatry, January 
2006; vol 163: pp 1-13. Insel, T.R. American Journal of Psychiatry, 
January 2006; vol 163. STAR*D web site. Madhukar Hariprasad 
Trivedi, MD, professor and director, mood disorders research 
program and clinic, University of Texas Southwestern Medical Center 
at Dallas. Andrew Elmore, PhD, psychotherapist; assistant clinical 
professor, Mt. Sinai School of Medicine, New York.*

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Best,
D :roll:


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