Correct mix of drugs may treat depression

The final stage of a landmark federal study on treating depression suggests two-thirds of patients eventually can be helped if they are patient enough to keep trying medications until they find one that works.

Thirteen percent of the 123 study participants who did not get better on the first three drugs they tried were helped by a fourth, researchers found.

But there is a downside to so many attempts: The more tries people made, the more likely it was that they later would relapse and slide back into depression.

"It's a sobering message when you get down to requiring three or four steps," said the chief researcher, Dr. A. John Rush, a psychiatrist at the University of Texas Southwestern Medical Center in Dallas. "It says that follow-up is critical" to make sure people stay on the drugs, he said.

The real-world study of 3,671 patients with major depression showed that no one drug or class of drugs works any better than another, the researchers said. The right combination must be found for each individual patient.

Results were published in the November issue of The American Journal of Psychiatry.

About 15 million Americans each year are diagnosed with depression, the nation's top mental-health problem. Drugs to treat the disorder have had only limited testing until now. The government began the six-year, $35 million study to test a variety of medications in "real world" settings: people seeking help at community clinics and doctor's offices.

The study adds to growing evidence that major depression is a chronic disease, said John Greden, executive director of the University of Michigan Depression Center in Ann Arbor.

Real-world success in treating depression may be considerably less than in the research, Greden said, because primary-care doctors write about 70 percent of prescriptions for antidepressants, and they're less likely to try multiple treatment steps.

The project started with 3,671 adults diagnosed with major depression. Half had a family history of it, and more than half had suffered multiple bouts.

All were started on Celexa, made by Forest Laboratories and one of a widely used class of drugs called SSRIs, for selective serotonin reuptake inhibitors. Nearly 37 percent had their depression go into remission after the first try.

The rest switched to another antidepressant or continued with Celexa and added a second treatment. This second step helped 31 percent of that group.

The third and fourth attempts brought success rates of 14 percent and 13 percent, respectively. When all results from these various groups were looked at collectively, 67 percent of the total group had been helped by one or more drugs.

However, 40 percent of those who achieved remission on their first drug relapsed within a year. That rose to 55 percent of those who took two tries to succeed and 65 percent and 70 percent of those requiring three and four tries, respectively.

"More steps are still worthwhile, but you have a decreasing return," Rush said.

Among the drugs used in the subsequent treatments were Effexor, a drug in a class called selective serotonin/norepinephrine reuptake inhibitors or SNRIs; nortryptyline, an antidepressant in an older class called tricyclics; Remeron, also known as mirtazapine; lithium; or T-3, a thyroid hormone.

Dr. Thomas Insel, director of the National Institute of Mental Health, said that because there was no comparison group of people who got no treatment, it is hard to know how many got better on their own, with enough passage of time or because of the drugs.

"I think the overall results are hopeful," he said. "The problem with depression is that people and their families feel hopeless. The message here is that medication can be helpful."

Soon to be published are separate results on the effectiveness of counseling, which some participants got in the second stage of the study.

Material from USA Today and Reuters is included in this report