# Doctor-patient teamwork plus patience can achieve full depression remission



## David Baxter PhD (Nov 2, 2006)

Doctor-patient teamwork plus patience can achieve full depression remission
Thursday, 2-Nov-2006

More than two-thirds of people who suffer from major depression can become symptom-free if they are willing to work with their doctors and try various treatments to determine which work best for them, which may involve taking different antidepressants or adding cognitive therapy to the mix. 

The largest study on treatments for depression, led by UT Southwestern Medical Center, found that 67 percent of patients achieved a full remission of symptoms by the end of one to four treatment steps. An overview of the $35 million, six-year study - designated STAR*D (Sequenced Treatment Alternatives to Relieve Depression) and funded by the National Institute of Mental Health (NIMH) - appears in the November issue of the _American Journal of Psychiatry_. 

Results showed that the chances of reaching remission were higher after the first and second treatment steps (37 percent and 31 percent respectively), than after the third and fourth steps (14 percent and 13 percent). For those who did improve or remit in fewer treatment steps, lower relapse rates were found during a 12-month follow-up than for those who required more steps to reach remission or improvement. 

"There's good news and not-so-good news," said Dr. A. John Rush, vice chairman of clinical sciences and professor of psychiatry at UT Southwestern. "The good news is that two-thirds of people can be relieved of their depression if they can hang in there for up to four treatment steps. That's pretty significant for a tough illness. The not-so-good news is that when more steps are needed to get to remission or meaningful improvement, the higher the risk is for having a return of the depressive episode - or a relapse," said Dr. Rush, the study's principal investigator. 

STAR*D is the first benchmark study to implement specific step-by-step medication treatment guidelines based on patients' symptoms and medication side effects. This gives clinicians a "measurement-based care" approach to delivering high-quality treatment for depression. 

An important feature of the landmark clinical trial is that the 3,671 patients included were treated in "real-world" settings - 41 primary-care and psychiatric clinics around the country - rather than being nonpatient volunteers, as often is the case in such studies. In addition to suffering from major depression, most had other coexisting general medical and psychiatric conditions. 

All participants initially received the same antidepressant medication. Those who didn't experience remission or couldn't tolerate the medication were strongly encouraged to proceed to the next step, where they were randomized to various groups receiving subsequent treatments including cognitive therapy alone or in combination with medication, as well as several different antidepressants used alone or in combination. Once patients achieved remission or made substantial improvement, they were followed closely for another 12 months. 

"This report provides a summary of all the steps and a comprehensive view of outcomes from the largest depression trial ever conducted," said Dr. Madhukar Trivedi, co-author of the study and professor of psychiatry at UT Southwestern. "It offers clear evidence of what happens step-by-step and gives us a good idea of what outcomes will be the following year, if patients continue the same treatment." 

Each year, about 21 million American adults - or 9.5 percent of the population - struggle with depression, often a recurring or chronic disorder. Depression frequently returns two or more times, with some episodes lasting two years or more. 

"Depression is a disabling medical condition just like any other medical condition such as diabetes or congestive heart failure," Dr. Rush said. "The take-home message for patients is to hang in there and stay in treatment, even if several steps and various medications must be tried. Be patient and willing to tell your doctor if a medication isn't working, if the dosage is bothering you or if you're having side effects. Collaborate with your physician to find the right medication and dosage for you, and stay on it long enough to give it a chance to work." 

For clinicians, the study emphasizes the need for careful and regular monitoring and evaluation of patients, as well as highlights the critical value of remission as the end objective, Dr. Rush said. 

"Remission is the thing you really, really want to try and achieve. And, follow-up is critical," he said. "The more steps it takes to get better or to remission, the more carefully a patient needs to be followed, because the more likely that individual is to have a relapse." 

While more research is needed, STAR*D offers "clues," Dr. Rush said, into the types of patients who require longer treatment for depression. These include people who suffer from other chronic medical conditions and/or additional psychiatric disorders, and individuals who have experienced longer and more disabling periods of depression before seeking treatment. 

As for the one-third of individuals who didn't reach remission, possible explanations include:


There may be some depressions for which medications don't work. 
Individual biological and genetic differences, as well as life circumstances and other medical conditions, may render some medication treatments ineffective. 
People suffering from long bouts of depression might have been helped earlier in the course of the disease, but may not achieve remission after lengthy chronic depression.
"This study emphasizes the importance of long-term management of this disease," Dr. Rush said. "The short-term matters, but the long-term matters even more." 

Rush AJ, Trivedi MH, Wisniewski SR, Nierenberg AA, Stewart JW, Warden D, Niederehe G, Thase ME, Lavori PW, Lebowitz BD, McGrath PJ, Rosenbaum JF, Sackeim HA, Kupfer DJ, Luther J, Fava M. *Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report. *_Am J Psychiatry_. 2006 Nov;163(11):1905-17.   [Abstract]


----------



## Cat Dancer (Nov 2, 2006)

> People suffering from long bouts of depression might have been helped earlier in the course of the disease, but may not achieve remission after lengthy chronic depression.



Does this mean if you've struggled with depression (untreated) most of your life, then you might not get well ever?


----------



## David Baxter PhD (Nov 2, 2006)

No. But it probably means that there is more deeply entrenched negative thinking and self-talk which will require more psychotherapy, especially CBT. The article above is more about response to medication alone or response to medication plus short-term psychotherapy including CBT.


----------



## Halo (Nov 2, 2006)

I have to say that at first reading this article it gave me a little hope especially reading this part



> "The take-home message for patients is to hang in there and stay in treatment, even if several steps and various medications must be tried.



But then reading further on the part where the hope for me started to fade was reading this



> As for the one-third of individuals who didn't reach remission, possible explanations include:
> 
> There may be some depressions for which medications don't work.




Just makes me think that I may fall into this category


----------



## David Baxter PhD (Nov 2, 2006)

> There may be some depressions for which medications don't work.


I suppose that's possible but remember these studies are limited in their scope. They are excellent studies but limited in scope nonetheless.

For people who do not respond to the treatments examined in these studies, there are other alternatives, including older-style antidepressants; so-called "medication cocktails", where other medications are added in to enhance the effectiveness of the SSRIs and/or alleviate the side-effects of higher SSRI doses; different psychotherapy approaches or longer periods of psychotherapy; or even nutritional approaches including B12 injections (which I personally have seen make a huge difference in one client especially).

And, as scary as it sounds, as a last resort for severe depression that does not respond to the above, there is always controlled ECT, which I have seen work wonders in two cases.


----------



## ThatLady (Nov 2, 2006)

I think, in your case, it's probably too early to come to that conclusion, Nancy. There are new medications coming out all the time, and I'm not sure you've tried all the various combinations yet. Don't give up hope until all avenues are exhausted! :hug:


----------



## Into The Light (Nov 2, 2006)

hi nancy, note that the article said "_possible_ explanations" - it's not a conclusion or fact at all. they are still researching and trying to find answers.

:hug:


----------



## Cat Dancer (Nov 2, 2006)

David Baxter said:


> No. But it probably means that there is more deeply entrenched negative thinking and self-talk which will require more psychotherapy, especially CBT. The article above is more about response to medication alone or response to medication plus short-term psychotherapy including CBT.



What does short-term mean? I guess I mean how long is "short-term?"


----------



## Halo (Nov 2, 2006)

I see all your points but just trying hard not to lose hope and yes TL I know that I have not tried ALL of the medications out there but I feel like I have tried many which just always seem to be the wrong ones. 

Anyway, good article nonetheless, very informative
(hope that wasn't too subtle of a change of subject)


----------



## David Baxter PhD (Nov 2, 2006)

Also note this part of the study:



> *In addition to suffering from major depression, most had other coexisting general medical and psychiatric conditions.*



So is it really that the depresion is resistant to treatment? Or is it more that these coexisting medical and psychiatric conditions interfered with or limited the effectiveness of treatment in some way?



			
				Janet said:
			
		

> how long is "short-term?"


It's a relative term but generally in such studies this is on the order of weeks. For someone entering treatment after years of chronic depression, that's almost certainly NOT going to be enough.


----------



## just mary (Nov 2, 2006)

> Each year, about 21 million American adults - or 9.5 percent of the population - struggle with depression



I know this shouldn't be a surprise to me but I'm still amazed at how prevalent depression is.  That's nearly 10% of the population.

Anyway, interesting article.  Just one question though, when they talk about "treatment steps", are they referring to trying different approaches?  For example, on a visit to your doctor he diagnoses you with depression and he gives you a prescription for zoloft but doesn't refer you to a therapist. After two months on zoloft only - you're still depressed. He then decides to keep you on zoloft but send you to a therapist.  Would this be two treatment steps?

Thanks,

jm


----------



## David Baxter PhD (Nov 2, 2006)

I think so, yes. Again, I believe the primary emphasis in the article is on trial-and-error with medications and/or medication/psythotherapy combinations.


----------



## David Baxter PhD (Nov 4, 2006)

Patients Should Consider Multiple Antidepressants
Friday, November 03, 2006

Patients who sense no relief from prescribed antidepressants need to be patient and consider trying alternate meds even as their chances of success decrease, according to a wide-scale federal study published in the November issue of the _American Journal of Psychiatry_. In one of the largest related projects to date, researchers began with 3,671 Americans suffering from major depression. All were medicated with Celexa, one of the most commonly prescribed SSRIs, and more than a third experienced significant remission while on the drug, but the 63% not satisfied by this initial treatment then shifted to alternate medications. As patients tried more drugs, they saw diminishing returns: 30.6% of those unhappy with Celexa reported success with a second medication, and those who moved on to a third or fourth treatment option reported success rates of 13.7% and 13%, respectively. The overall remission rate was near 67%, which is a very encouraging number, but those who move through multiple medications with no relief in sight may find it harder to hope for success. 

Some patients are obviously less responsive to the drugs in question, but for those suffering from seemingly insurmountable depression, the failure of one or two trials need not serve as a sign of defeat. The possibility that other drugs may be more effective should encourage patients to consider alternate treatments, but the more drugs one tries without noticeable success, the less likely he or she is to acheive the desired results. These patients also predictably run a greater risk of future relapse:

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.​
Of course, this study only considered the impact of controlled chemical agents, not accounting for important factors such as financial circumstances, personal relationships and participation in therapy regimens that can greatly influence levels of depression. The study also did not include a control group who received no medication, therefore leaving out the sizable percentage of patients who recover on their own. Further studies will focus on the counseling variable, which is often just as important as medication. The fact is that depression is an extremely complex affliction and that effective remedies vary widely from case to case. Some patients have to pass through multiple trials in order to determine the best methods of treatment, but their patience and persistence may ultimately be rewarded. 

“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.​


----------

