What do you do if you’re suffering from depression and are not responding to antidepressant treatment? Now the government-sponsored STAR*D study provides evidence-based guidelines to help you and your doctor find the right answer.
After failure on an antidepressant, the next step you and your doctor decide to take is largely a matter of trial and error based on your doctor’s experience with other patients, your medical history, and your doctor’s consultation with other mental health professionals. This trial-and-error approach may soon be a thing of the past, however.
Results from the largest and longest study ever done to evaluate depression treatment -- the Sequenced Treatment Alternatives to Relieve Depression trial, or STAR*D -- are starting to give doctors some evidence-based guidance toward optimal next-step strategies. The study, which looked at the use of popular antidepressants in people with chronic depression -- lasting, in some cases, 15 -16 years -- is the first to provide “real-world” scientific data on what to do when someone doesn’t respond to a particular antidepressant, has severe depression, or suffers from multiple mental and physical ailments. These types of treatment-resistant patients are not typically included in antidepressant drug trials sponsored by pharmaceutical companies.
By contrast, STAR*D is a government-sponsored study, funded by the National Institute of Mental Health. It didn’t shy away from including these difficult-to-treat patients, and it was designed to mimic real-word treatment settings. Moreover, STAR*D is an effectiveness trial, which typically asks tougher questions than traditional efficacy trials. Effectiveness trials measure symptom reduction and patient function, and also take into account the complex and sometimes messy realities that clinicians face in everyday practice. The goal of STAR*D was remission, because people who become symptom-free generally function better and are less prone to relapse. Efficacy trials normally seek only a reduction in symptoms. What all this means is that the results of STAR*D are immediately relevant to you and your doctor, especially if you’re still searching for a drug regimen that will effectively treat your depression.
Take-home messages from the STAR*D study on antidepressants:
One antidepressant treatment does not fit all. You may need to try several antidepressants to find a drug regimen that works for you.
Persevering through several different treatment attempts, as arduous as that may be, can improve results for many people.
At standard doses of the most commonly used class of antidepressants -- selective serotonin reuptake inhibitors (SSRIs) -- 30% of patients with severe depression achieve remission with the first antidepressant prescribed.
It often takes 12 weeks to achieve an adequate response to an antidepressant, not the standard four to eight weeks that most doctors and mental health specialists were previously using to guide decisions.
If the first choice of an antidepressant does not provide adequate symptom relief, switching to a new antidepressant is effective about 25% of the time.
Switching from one SSRI to another is almost as effective as switching to a drug from another class.
If the first choice of antidepressant does not provide adequate symptom relief, adding a new antidepressant while continuing to take the first medication is effective in about one-third of people.
For people who don’t respond to first-line therapy with an SSRI, adding a second drug to the SSRI drug regimen appears to be slightly better than completely switching medications.
For those who don’t respond to switching to a new antidepressant or adding a second drug, trying a third medication can still help about one in five people.
Excerpted from The Johns Hopkins Depression and Anxiety Bulletin, Fall 2006 Issue
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Special Report #1: Antidepressants: If the First Drug Doesn't Work, Don't Give Up Physicians now have a growing array of options to consider in prescribing antidepressant drugs — including selective serotonin reuptake inhibitors (SSRIs), tricyclics, tetracyclics, dopamine reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, and monoamine oxidase (MAO) inhibitors. Our Special Report will help you understand the pros and cons of different drug therapies — and find out why many patients benefit from switching or combining medications. Essential reading for anyone considering, or being treated with, antidepressants.
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