Depression study urges persistence

When treatment with one drug fails, adding or changing medicine often works


In the long and frustrating battle against depression, persistence does pay.

A major new government study reported yesterday that at least a quarter of depressed patients who fail to achieve a complete remission with their first course of drug treatment can do so by adding on a second drug or by switching drugs.

Overall, about half of the nearly 1,500 patients in the study achieved remission - the virtually complete absence of symptoms - by completing two treatment steps, and many others showed improvement.

"This is the largest study ever to look at what is the best next step if you don't get well in the first step" of treatment, said Dr. Andrew Leuchter of UCLA, who participated in the study.

Many patients also give up if they don't get an immediate response with the first drug they try or if they suffer unpleasant side effects.

The message to patients and physicians is "Hang in there," said Dr. A. John Rush of the University of Texas Southwestern Medical Center, who led the trials reported yesterday in The New England Journal of Medicine. "For the depressed person, it may not matter so much what drug is being prescribed, but that the person moves forward and keeps trying."

Depression is a devastating illness that affects nearly 15 million Americans each year and is the leading cause of disability between the ages of 15 and 44.

But little progress is being made because half of all depressed patients do not receive treatment and only 40 percent of those who are treated receive a regimen dictated by scientific research.

The Sequenced Treatment Alternatives to Relieve Depression study, commonly known as STAR*D, is designed to address those issues.

The study initially enrolled nearly 3,000 patients who had suffered from depression for an average of 16 years. Two-thirds had other medical problems and 40 percent were unemployed because of their condition.

All the patients received citalopram, trade-named Celexa. That drug was chosen because it was relatively new at the time, could be easily given in various doses and seemed to be well-tolerated.

Nonetheless, about 20 percent of patients dropped out because of side effects.

Overall, about one in every three patients given the drug went into remission. The doses used were often higher than those in everyday practice and patients were followed for as long as 12 weeks - a crucial change, according to Rush.

Often, patients and doctors abandon a drug if they don't see results within four weeks, he said. But about half the patients in the study who improved did not show benefits until eight to 10 weeks into the study.

In the second level of the study, patients who did not go into remission were given the option of having a second drug added to their regimen or of switching drugs.

Of those, 727 chose to switch and were randomly assigned to receive either sertraline (Zoloft), bupropion (Wellbutrin) or venlafaxine (Effexor).

In that group, about 25 percent achieved remission within 14 weeks, regardless of which drug they received.

Somewhat surprisingly, Rush said, the three drugs each had a different mode of action, but all produced about the same results. The team had thought that patients might not respond to sertraline, which is in the same class as citalopram.

Thomas H. Maugh II writes for the Los Angeles Times.

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