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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 13 of 13. This is the beginning of the thread.
Posted by jerrympls on March 23, 2006, at 1:00:09
MSNBC.com
Depression drugs work in just half of patients
Medications may be more effective on second try, study findsBy Shankar Vedantam
The Washington Post
Updated: 12:44 a.m. ET March 23, 2006Antidepressants fail to cure the symptoms of major depression in half of all patients with the disease even if they receive the best possible care, according to a definitive government study released yesterday.
Significant numbers of patients continue to experience symptoms such as sadness, low energy and hopelessness after intensive treatment, even as about an equal number report an end to such problems -- a result that quickly lent itself to interpretations that the glass was either half empty or half full.
The $35 million taxpayer-funded study was the largest trial of its kind ever conducted. It provided what industry-sponsored trials have rarely captured: Rather than merely ask whether patients are getting better, the study asked what patients most care about -- whether depression can be made to disappear altogether.
‘Illuminating and disconcerting’
The study has been eagerly awaited by physicians, patients and the pharmaceutical industry. According to government statistics, depression afflicts 15 million Americans a year. About 189 million prescriptions for antidepressants were written last year, and the disease costs the nation $83 billion annually because of treatment costs, lost productivity, absenteeism and suicide.David Rubinow, a professor and the chairman of the psychiatry department at the University of North Carolina at Chapel Hill, said the results are an "illuminating and disconcerting" window into the affliction that is thought to fuel many of the 30,000 suicides committed each year in the United States.
Although the study showed that patients who do not respond well to one drug could be helped by another, the results are "discouraging for several reasons," Rubinow said in an editorial published in the New England Journal of Medicine, which also published the study.
It is troubling that large numbers of patients continued to have problems, he said. Additionally, he noted that the drugs used in the study -- Celexa, Wellbutrin, Zoloft and Effexor -- work in very different ways yet had roughly equal effectiveness when it came to treating depression. This suggests that the underlying brain mechanisms of depression are far more complicated than simple notions of a single chemical imbalance.
Thomas Insel, director of the National Institute of Mental Health, which funded the study, emphasized that patients should seek -- and stick with -- treatment. "The glass is half full from our perspective," he said. But "the glass is half empty in that we need to come up with better treatments in the future."
Better results on second try
The study is immediately relevant to physicians because it tracked a large number of patients with the kind of complications and chronic problems that are usually excluded from pharmaceutical industry trials. About one in three patients had seen their depression symptoms go away after an initial round of treatment, a result known as remission. About half achieved that goal after a new round of treatment involving either a new medication or an additional drug, the research found.Although patients recruited to pharmaceutical industry trials are usually carefully screened to ensure they do not have other psychiatric or medical conditions, those in the government-funded study often suffered from multiple physical and mental problems -- typical of patients whom doctors routinely see.
At the same time, the researchers acknowledged, the care provided in the study was exceptional. Intensive monitoring and careful evaluation was provided to all patients. Such services are available today in perhaps one in 10 medical practices. If the patients in this study had received the kind of care that patients receive on average, the researchers said, the remission rate probably would have been significantly lower -- perhaps even in the single digits.
"People who entered into this trial received a level of care which is quite different than many patients receive when they see a primary-care doc or even a psychiatrist," Insel said as he described what clinical facilities should aim for in terms of care. "This involved a depression-care specialist who made sure there was very careful monitoring of side effects and a relentless effort to optimize the dose. It is not like writing a prescription for penicillin and coming back in four to six weeks."
Deep look into the minds of patients
The study also employed standardized assessment tests that looked more deeply at patients' conditions than the routine conversations about their health that are generally employed in clinical care. Such attention allowed problems to rise to the surface that may otherwise be missed, and kept patients from becoming discouraged about treatment.Augustus John Rush, a psychiatrist at the University of Texas Southwestern Medical Center in Dallas, who helped organize the study known as the Sequenced Treatment Alternatives to Relieve Depression, said the results are positive, given the many complications that often accompany depression.
"A 50 percent remission rate is extraordinarily good, given the nature of these disorders," he said. "These individuals have had an average of 16 years of depression. Two-thirds have other concomitant psychiatric conditions and two-thirds have concomitant general medical problems. All of these reduce the chances of remission."
Although the study has continued to offer treatment for even longer periods, those results are not yet available. Rush said that with chronic problems, most of the benefit is usually seen in the first couple of rounds of treatment, since the remaining patients are those with the most intractable problems.
Psychiatric drugs have been at the center of growing controversy for nearly two years -- including concerns that antidepressants may increase the risk of suicidal behavior among some children and worries that drugs used to treat attention deficit hyperactivity disorder are overused. Still, researchers and clinicians say they are far more worried about untreated mental illness than any overuse of medications.
© 2006 The Washington Post Company
© 2006 MSNBC.com
Posted by Meri-Tuuli on March 23, 2006, at 4:38:47
In reply to Depression drugs work in just half of patients, posted by jerrympls on March 23, 2006, at 1:00:09
And thats just for the patients who get 'optimal' treatment.
I'm glad this research came out and was conducted in the first place! Good on you US government!
Posted by greywolf on March 23, 2006, at 7:34:19
In reply to Depression drugs work in just half of patients, posted by jerrympls on March 23, 2006, at 1:00:09
As long as the study leads to a greater effort to find new and more effective meds, I'm glad the study was done.Unfortunately, I see this going in a different direction. Insurers and HMOs will use this study as justification to restrict access to drugs that are effective for that other half of the treatment population. The FDA will probably take an even tougher stand on new meds, meaning even fewer of the drugs that the rest of the world enjoys will ever make it into the American market.
Cheerlead the study all you want, but the reality is that depression, BP, OCD, etc., are extraordinarily difficult illnesses to treat. A success rate even approaching 50% for depression should, in my humble opinion, be applauded, not criticized. There is certainly room for valid criticism, but given the importance of these meds for so many people, it should be directed at specific ineffective drugs or treatment programs.
Mark my words, this study will be misused and abused by the "it's all in your mind" and the "just suck it up and get on with life" crowd.
Posted by SLS on March 23, 2006, at 8:01:17
In reply to Re: Depression drugs work in just half of patients, posted by greywolf on March 23, 2006, at 7:34:19
> Cheerlead the study all you want, but the reality is that depression, BP, OCD, etc., are extraordinarily difficult illnesses to treat. A success rate even approaching 50% for depression should, in my humble opinion, be applauded, not criticized.
Agreed.
> There is certainly room for valid criticism, but given the importance of these meds for so many people, it should be directed at specific ineffective drugs or treatment programs.
Agreed.
> Mark my words, this study will be misused and abused by the "it's all in your mind" and the "just suck it up and get on with life" crowd.
I wish I could disagree here. Unfortunately, I think you are probably right.
- Scott
Posted by Meri-Tuuli on March 23, 2006, at 8:25:21
In reply to Re: Depression drugs work in just half of patients, posted by greywolf on March 23, 2006, at 7:34:19
> Unfortunately, I see this going in a different direction. Insurers and HMOs will use this study as justification to restrict access to drugs that are effective for that other half of the treatment population. The FDA will probably take an even tougher stand on new meds, meaning even fewer of the drugs that the rest of the world enjoys will ever make it into the American market.
Do you think? I thought (and I could be wrong) that most of the drugs the FDA declines is more to do with big pharma company politics etc. I dunno.
But I would like to point out that although we (I am in the UK) might have a greater plethora of drugs to theortically chose from, it doesn't mean that pdocs/docs actually prescribe them.
In general, its difficult to find a pdoc that will prescribe a MAOI or a stimlant let alone some of the drug regimens that I have seen american posters here take like a benzo + SSRI + stimulant + sleeping med for instance.
Posted by DanielJ on March 23, 2006, at 8:28:07
In reply to Re: Depression drugs work in just half of patients, posted by SLS on March 23, 2006, at 8:01:17
I certainly sympathize with those who ADs don't help but 50% success rate is high compared to many drugs used in other fields. We consider ourselves lucky in that Zyprexa eliminates most of my son's Schizophrenia symptoms. In addition Zoloft gets rid of nearly all of the depression and "flat affect" connected with the illness. There are probably tens of thousands of successful case histories in most areas of MI that ADs are helping and that's nothing to scoff at.
Posted by SLS on March 23, 2006, at 9:35:23
In reply to Re: Depression drugs work 50% is great!, posted by DanielJ on March 23, 2006, at 8:28:07
Positive spin.
----------------------------------------
U.S. Department of Health and Human Services
NATIONAL INSTITUTES OF HEALTH
NIH News
National Institute of Mental Health (NIMH)
http://www.nimh.nih.gov/EMBARGOED FOR RELEASE: Wednesday, March 22, 2006; 5:00 p.m. ET
CONTACT: NIMH Press Office, 301-443-4536, NIMHpress@nih.gov
NEW STRATEGIES HELP DEPRESSED PATIENTS BECOME SYMPTOM-FREE
Results of the nation's largest depression study show that one in three
depressed patients who previously did not achieve remission using an
antidepressant became symptom-free with the help of an additional
medication and one in four achieved remission after switching to a
different antidepressant. The study, funded by the National Institutes
of Health's National Institute of Mental Health (NIMH), shows that
people whose depression is resistant to initial treatment can achieve
remission -- the virtual absence of symptoms -- when treated with a
second strategy that either augments or switches medications. This is
the first study to examine the effectiveness of different treatment
strategies for those who did not become symptom-free after initial
medication.John Rush, M.D., and Madhukar H. Trivedi, M.D., of the University of
Texas Southwestern Medical Center (UTSWMC), and colleagues report on the
first major results of the clinical trial, known as the STAR*D
(Sequenced Treatment Alternatives to Relieve Depression) study, in two
papers published in the March 23, 2006 issue of the "New England Journal
of Medicine"."These findings provide important treatment options to mental health
clinicians and the millions of Americans who struggle with
treatment-resistant depression," said NIH Director Elias A. Zerhouni,
M.D.Patients who did not experience a remission of symptoms during the first
level of the Star*D study -- in which they initially took the
antidepressant citalopram, a selective serotonin reuptake inhibitor
(SSRI), for up to 14 weeks -- were eligible to enter level 2 of the
trial where they were offered additional treatment options designed to
help them become symptom-free."If the first treatment attempt fails, patients should not give up,"
said NIMH's director Thomas Insel, M.D. "By remaining in treatment, and
working closely with clinicians to tailor the most appropriate next
steps, many patients may find the best single or combination treatment
that will enable them to become symptom-free."The 1,439 patients who were eligible and volunteered to enter level 2
were presented with seven different treatment options. Only very few
participants said that all of the choices were equally acceptable and
allowed themselves to be randomly assigned to any one of them. All the
rest of the participants identified at least one of the treatments as
being unacceptable, and chose to limit the treatments to which they
would allow themselves to be randomly assigned. Fifty-one percent (727)
of the patients chose options that included switching to a different
medication and were randomly assigned to one of the three switch
medications. Thirty-nine percent (565) chose options that included
augmenting the citalopram they were already taking, and were randomly
assigned to one of the two augmenting medications.The 727 patients who received the switch medication treatments were
randomized to take one of three medications currently available and used
in practice -- sertraline (an SSRI that targets the neurotransmitter
serotonin), bupropion-SR (a non-SSRI antidepressant), or venlafaxine-XR
(an agent that targets serotonin and norepinephrine, another
neurotransmitter).Rush and colleagues found that 25 percent of the patients who switched
to a new medication became symptom-free within 14 weeks; this was
similar within each of the three treatment groups. Additionally, no
significant differences were found in the efficacy, safety or
tolerability of the three medications to which patients were switched."Contrary to what previous research suggests, this study shows that all
three medications the patients switched to, despite having different
mechanisms of action, appear to be useful options for treating
depression following failure on the first SSRI," said Rush. "The results
provide patients and doctors with important information that intolerance
or lack of efficacy with one SSRI seems not to predict the same with
another."The 565 patients who received the augment medication were randomized to
take either bupropion-SR (a non-SSRI antidepressant) or buspirone (a
medication that enhances the action of an SSRI) in addition to the SSRI
citalopram that they were already taking in Level 1. Within 14 weeks of
using either treatment, about one third of the patients who enrolled in
the augmentation study became symptom-free, Trivedi and colleagues
reported. Both combinations appeared similar in terms of remission;
however, those who augmented citalopram with bupropion-SR experienced
fewer symptoms, a greater degree of symptom relief and lower side
effects compared to those who augmented with buspirone."Augmenting the first medication may be an effective way for people with
depression to become symptom-free," said Trivedi. "Augmenting earlier in
the course of treatment, or perhaps prescribing a combination of drugs
to patients initially, may be more effective than using one treatment
alone."According to the researchers, the switch and augment treatments cannot
be directly compared because of the way the trial was designed. The
results, however, can be used to help guide treatment choices within
each group; it also may be that different people respond better to one
as opposed to another treatment."Further research may help customize the treatment to the individual
patients," says Rush. Study participants who still did not achieve
remission in level 2 had the option of completing up to two additional
levels of treatment. Results from levels 3 and 4 of the STAR*D trial
will be published later this year.STAR*D is part of an overall NIMH effort to conduct practical clinical
trials in "real world" settings that address public health issues
important to those persons affected by major mental illnesses.
Posted by greywolf on March 23, 2006, at 9:43:01
In reply to Re: Depression drugs work in just half of patients » greywolf, posted by Meri-Tuuli on March 23, 2006, at 8:25:21
I would not be surprised at all to hear the Bush Administration proposing stricter controls on the prescribing of ADs and the introduction of new ADs into the market just so the Administration looks like it's doing something to control the rise of health care costs.
Believe me, in this country right now, there will be little support for restricting drugs used for the treatment of cancer, AIDS, and other physiological illnesses, but meds for mental illness will be fair game. A huge portion of the American population will buy into the "pull yourself up by your bootstraps" approach to treatment of mental illness, and those ubiquitous Lucinda Bassett mental wellness ads that impliedly denigrate those who take ADs and other drugs will become all that more common.
This study is not likely to be a good thing for those whose lives are actually improved by ADs. I think it's important, therefore, to accentuate the positives of current pharmaceutical treatments because an attack on ADs can lead to an attack on lots of other drugs.
Seriously, can you imagine the accolades that would be bestowed on the researchers who create a med that cures or significantly helps 50% of lung cancer patients? How about a drug that is effective for 50% of AIDs patients?
I wish it were better, but 50% is much preferable to 0.
Posted by linkadge on March 23, 2006, at 11:28:33
In reply to Re: Depression drugs work in just half of patients, posted by greywolf on March 23, 2006, at 9:43:01
I agree with you. Recent polls show that people's faith in the safety, but more importantly efficacy, have significantly dropped as a result of recent claims about AD's, suicidiality etc.
Linkadge
Posted by JaclinHyde on March 23, 2006, at 14:13:39
In reply to Re: Depression drugs work in just half of patients » greywolf, posted by linkadge on March 23, 2006, at 11:28:33
And yet they are still coming out with new drugs and coming up with new ideas. The MAOI patch and Abilify are just two examples. Until abilify came along my 10 year old sons bipolar disorder was out of control. And he had tried everything. Within 4 days he was a sweet and almost normal kid. I saw him smile that day, something he hadn't done in quite awhile.
Sorry, getting of the soapbox :-)
JH
Posted by Phillipa on March 23, 2006, at 20:45:53
In reply to Re: Depression drugs work in just half of patients, posted by JaclinHyde on March 23, 2006, at 14:13:39
At this point I don't know what to think . Either the side effects force me off the meds or they have none but do nothing. Help suggestions. Love Phillipa
Posted by Caedmon on March 25, 2006, at 13:59:14
In reply to Depression drugs work in just half of patients, posted by jerrympls on March 23, 2006, at 1:00:09
Posted by tizza on March 25, 2006, at 16:53:22
In reply to Re: Depression drugs work in just half of patients, posted by Phillipa on March 23, 2006, at 20:45:53
Well all I can say is the all the AD's I have tried over the last 11 years have done nothing but give me major grief but there is one in the pipe line that I would give a go if I slipped back into a depressive state and it works on melatonin. It's not approved yet but the EU are looking at it very closely. It called Agomelatine ( Valdoxan ) and it's meant to help with depression, anxiety and INSOMNIA. Could just be another one to add to the useless list but it works differently to all other AD's. Here's hoping. Paul
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