http://www.medscape.com/viewarticle/444198

Journal Watch Psychiatry
October 9, 2002

We Still Need to Do a Better Job of Treating Depression

from Journal Watch

Physician-authored summaries and commentary
from the publishers of the New England Journal
of Medicine

Posted 11/20/2002

Summary

Twenty years ago, the National Institute of Mental Health Collaborative Depression Study showed that many depressed patients received inadequate treatment. Results from 2 recent studies indicate that undertreated depression and low remission rates still exist.

For 3 months, researchers naturalistically followed 165 outpatients who were treated for major depressive episodes. Patients' overall rate of recovery was 30%. Of the 65% of patients who were prescribed an antidepressant, 31% did not receive adequate pharmacotherapy (4 weeks' treatment with, e.g., >125 mg of desipramine or >20 mg of fluoxetine). Of patients who received pharmacotherapy, those whose treatment was adequate were 3 times more likely to recover than the others were. Psychotherapy of any duration did not predict recovery.

In a continuation of a manufacturer-supported study comparing short-term treatments for chronic major depression, dysthymia, or double depression, other investigators re-randomized 161 sertraline responders to receive maintenance sertraline or placebo. By 76 weeks (completers were 55 patients who remained in remission), maintenance-sertraline patients had significantly fewer depression recurrences than did placebo patients (6% vs. 23%) and were half as likely to experience returning depressive symptoms (26% vs. 50%). Psychosocial functioning in remitted patients did not improve beyond initial short-term gains, but it deteriorated as soon as depression re-emerged. Among patients who remained healthy, sertraline was associated with better psychosocial functioning than placebo, although not all psychosocial functions were normal, even in maintenance-sertraline patients.

Comment

In the first study, many patients did not receive antidepressants, and almost one third of prescriptions failed to meet modest criteria for adequate pharmacotherapy. The second study confirms that long-term antidepressant therapy significantly reduces the risk for re-emerging depressive symptoms and psychosocial impairment, but that even remitted patients may have residual social dysfunction. Vigorous pharmacotherapy and add-on psychosocial therapies are often necessary to achieve complete recovery, which reduces the risk for recurrence. Some critics of medication emphasize the 35% placebo-response rate in studies of major depression; however, psychosocial function improves less with placebo than with medication, even in moderately depressed patients.

— Steven Dubovsky, MD

Source

Meyers BS et al. Predictors of early recovery from major depression among persons admitted to community-based clinics: An observational study. Arch Gen Psychiatry 2002 Aug; 59:729-35.

Kocsis JH et al. Psychosocial outcomes following long-term, double-blind treatment of chronic depression with sertraline vs placebo. Arch Gen Psychiatry 2002 Aug; 59:723-8.