[Mb-civic] Drugs Cure Depression In Half of Patients - Washington Post

[William Swiggard]

Drugs Cure Depression In Half of Patients
Doctors Have Mixed Reactions To Study Findings

By Shankar Vedantam
Washington Post Staff Writer
Thursday, March 23, 2006; A01

Antidepressants 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.

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."

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."

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.

http://www.washingtonpost.com/wp-dyn/content/article/2006/03/22/AR2006032202450.html?nav=hcmodule
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