Follow-up called key in treating depression

Two studies have mixed news for adults suffering from depression: New drugs can help, and pose little risk.

But to benefit, most patients will need plenty of follow-up care from their doctors until the right drug and dose are found. Reports on both studies appear in the January edition of American Journal of Psychiatry.

Findings in a 10-year Group Health study were contrary to a 2004 federal advisory that warned suicidal behavior could follow onset of treatment with newer antidepressants.

The Group Health study found suicide risk fell 60 percent right after beginning treatment, and declined further after five months.

The study, which was funded by the National Institute of Mental Health, also found the risk of suicidal behavior after starting the newer drugs — including Paxil, Zoloft, Celexa and Prozac — was less than the risk posed by older medications.

The study was based on computerized medical and pharmacy records for more than 65,000 patients who filled prescriptions for antidepressants from 1992 to 2003. Deaths by suicide were determined from death certificates, and suicide attempts were identified from hospital-discharge data.

Controversy about antidepressants and suicide has focused particularly on use of the drugs by depressed adolescents.

Common symptoms of depression


Persistent feelings of sadness

Trouble sleeping, especially waking in the middle of the night

Loss of ability to concentrate or enjoy usual activities

Feeling hopeless or worthless.

Researchers did find a higher rate of suicide attempts among adolescents than among adults — 324 per 100,000 for youths versus 78 for adults in the first six months of treatment.

But the rate was highest in the month before treatment, and declined by about 60 percent after treatment began, just as with adults.

The Group Health study does not mean some people won't have a bad reaction to the drugs. "In a study like this we look at averages," said lead researcher Dr. Gregory E. Simon, a psychiatrist and researcher with Group Health Cooperative. "The best predictor is what happened to everyone else, but that does not mean some don't have a bad reaction."

The findings belie popular misconceptions that may have discouraged some sufferers from seeking treatment.

"The conventional wisdom for years was that people's risk of suicide goes up after taking medication, but that is not true," Simon said. "When you try to take it back to evidence, there isn't any."

Information

National Institute of Mental Health: www.nimh.nih.gov/

Depression and Bipolar Support Alliance: www.dbsalliance.org/

Sequenced Treatment Alternatives to Relieve Depression (Star*D): www.star-d.org

Follow-up is key

A separate study at the University of Texas Southwestern Medical Center found, according to The Associated Press, that only one in three patients with serious depression recover with the first drug treatment they try.

Follow-up care is important, Simon agrees, for everyone taking antidepressants. Not because the drugs are dangerous but because for so many people, the drugs are ineffective on the first try. The dose or the drug may be incorrect.

Of 2,000 people who take antidepressants, one will die by suicide and three will make an attempt serious enough to wind up in the hospital, according to the Group Health study. But fully 800 will not get better, Simon said. They need to determine a new course of action with their doctor in a follow-up visit.

The Texas study showed that a third of people suffering serious depression recover with the first antidepressant they try, and well-educated white women are most likely to benefit.

One key finding: Patients whose symptoms of depression disappeared took higher-than-typical drug doses and received close monitoring and frequent dose adjustments in the first three months — a level of care that few U.S. patients today receive.

When treatment fails

The main goal of the Texas study is to identify what harder-to-treat patients should try when initial treatment fails, instead of abandoning therapy in frustration. Those results are due in a few months.

Psychiatrists have long known that for most depression sufferers, the first antidepressant choice won't be a panacea, just as patients with epilepsy, heart disease or cancer often must mix and match medications before finding the best solution.

But unlike those illnesses, physicians have had little scientific evidence until now to guide their choices or to help them maximize each patient's chances of benefit.

"Tailor the treatment," emphasized Texas researcher Dr. Madhukar Trivedi, who reported first results from the study.

How? The study created an easy-to-use rating system to quickly assess depression symptoms and report drug side effects.

That rating system — called STAR*D (Sequenced Treatment Alternatives to Relieve Depression) and now posted on a Web site for any doctor to use — allows patients' drug doses to be adjusted every two to three weeks until they hit the right balance, or until it becomes clear that some other therapy is needed.

It's rare today that people under treatment with antidepressants receive this type of care, said Dr. Richard Nakamura, deputy director of the National Institute of Mental Health.

"Many people, because they're not given follow-up, the medications aren't adjusted ... do end up being frustrated, and any negative side effects, any trouble with dosage levels, will cause them to end treatment," Nakamura said.

A bonus: The ratings have led to closer physician monitoring, with five to six visits during the critical first months of antidepressant use.

Depression is a common and treatable illness. It affects 6 percent of the American public in any given year, and 15-20 percent of Americans over their lifetimes.

Lynda V. Mapes: 206-464-2736 or lmapes@seattletimes.com

Information from The Associated Press was included in this report.