One of the largest studies of depression and depression treatments has finally been written up in the New England Journal of Medicine. The study, called Sequenced Treatment Alternatives to Relieve Depression, was financed with an estimated $35 million of taxpayers money through the National Institute of Mental Health, a number that appears enormous, but pales in comparison to the esxtimated $83 billion that depression costs the country each year.
The Washington Post has two stories out today on the study. The first takes a relatively positive approach to some of the results, the second, a much more negative one. For its part, the WaPo's first story explains that, according to results of the study, (which has been nicknamed STAR*D) one third of patients who were unsuccessful at achieving remission of their depression symptoms after initial treatment did so after switching treatments by either adding a second drug or switching drugs altogether.
The clear message, doctors said, was that antidepressants should be given a 6-to-12-week chance to work and that if one doesn't help, another should be tried.
"It's important not to give up if the first treatment doesn't work fully," or causes side effects, said one study leader, Dr. John Rush of the University of Texas Southwestern Medical Center in Dallas.
The second story, while echoing some of the optimism of the first, runs with the headline "Drugs Cure Depression in Half of Patients." Essentially, the story goes on to say, that while switching drugs helps an extra third of patients improve their outcomes, still a whole fifty percent of those in the study didn't improve with any kind of drug treatment. The problem with this type of press coverage is that it can be discouraging because it seems to place all the hope of derpession treatment into the basket of medication.
The WaPo story mentions, on more than one occasion, that the subjects received "the best possible care," and still did not achieve their expected outcomes. But there are two very important qualifiers at play. As one study organizer noted, the cases they were dealing with were some of the most severe cases of depression, with participants having experienced symptoms for an average of 16 years. Also, the WaPo article makes no mention whatsoever of psychotherapy being used in conjunction with the drug treatments. (At this point it is important to note that Stage 2 of STAR*D did indeed include "talk therapy" as one of the alternative options, but at no point was that addressed in the media coverage. See the NIMH press release of the study here.)
While final judgement can be reserved for the findings of stages 3 and 4 to be released, what I want to communicate here is that depression, and specifically major depression should never be treated with medications alone. The reporting in the Post makes it sound as if "the best possible treatment" for depression is some combination of drugs and "thorough" dosage monitoring. This is something that drug companies would love to have patients believe. One comment that is tossed into the middle of the article is as follows:
It is troubling that large numbers of patients continued to have problems, [David Rubinow, a professor and the chairman of the psychiatry department at the University of North Carolina at Chapel Hill] 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.
Its obvious that the writer took this out of context from Rubinow's editorial in the NEJM, and in so doing he does a disservice to the professor by attributing such a juvenile approach to the disease to him. Depression is extremely complicated, and while the idea of some wonder drug is a nice one to have, it is simply not a reality, and may never be.
The very nature of depression requires a multi-modal approach to treatment, one that embraces medication, when that avenue is warranted. As the STAR*D program moves forward, it would be helpful to hear more about the research into other types of treatment, whether they be traditional therapy or online treatments. In either case, the important thing to remember is that depression is a chronic problem that requires a chronic solution. The push toward greater reliance on drugs can be almost exclusively attributed to insurance companies who would hope that by finding the miracle treatment, they could elimate the need for continuous treatment which can obviously cost them a great deal. (Also, don't think for a minute that I'm excusing the drug companies for the manner in which they continue to push drugs as a "cure" for depression.)
These most recent reports should be seen as a postive step toward greater understanding about depression, but should not be viewed as negative or discouraging. Conquering depression and acheiving remission will take creative approaches from primary care physicians, researchers, psychiatrists, psychologists and patients. It will also require the news outlets such as the Washington Post to cover these extremely complicated trials more thoroughly and completely. All are intergral parts of the continuing search for improved mental health. |