Carefully Monitored Treatment Can Help Two-thirds of Those Who Suffer from Depression

More than two-thirds of people who suffer from major depression can become symptom-free if they are willing to work with their doctors and try various treatments to determine which work best for them, which may involve taking different antidepressants or adding cognitive therapy to the mix.

The largest study on treatments for depression, led by UT Southwestern Medical Center, found that 67 percent of patients achieved a full remission of symptoms by the end of one to four treatment steps. An overview of the $35 million, six-year study – designated STARD (Sequenced Treatment Alternatives to Relieve Depression) and funded by the National Institute of Mental Health (NIMH) – appears in the November issue of the American Journal of Psychiatry.

Results showed that the chances of reaching remission were higher after the first and second treatment steps (37 percent and 31 percent respectively), than after the third and fourth steps (14 percent and 13 percent). For those who did improve or remit in fewer treatment steps, lower relapse rates were found during a 12-month follow-up than for those who required more steps to reach remission or improvement.

“There’s good news and not-so-good news,” said Dr. A. John Rush, vice chairman of clinical sciences and professor of psychiatry at UT Southwestern. “The good news is that two-thirds of people can be relieved of their depression if they can hang in there for up to four treatment steps. That’s pretty significant for a tough illness.

“The not-so-good news is that when more steps are needed to get to remission or meaningful improvement, the higher the risk is for having a return of the depressive episode – or a relapse,” said Dr. Rush, the study’s principal investigator.

STAR*D is the first benchmark study to implement specific step-by-step medication treatment guidelines based on patients’ symptoms and medication side effects. This gives clinicians a “measurement-based care” approach to delivering high-quality treatment for depression.

An important feature of the landmark clinical trial is that the 3,671 patients included were treated in “real-world” settings – 41 primary-care and psychiatric clinics around the country – rather than being nonpatient volunteers, as often is the case in such studies. In addition to suffering from major depression, most had other coexisting general medical and psychiatric conditions.

All participants initially received the same antidepressant medication. Those who didn’t experience remission or couldn’t tolerate the medication were strongly encouraged to proceed to the next step, where they were randomized to various groups receiving subsequent treatments including cognitive therapy alone or in combination with medication, as well as several different antidepressants used alone or in combination. Once patients achieved remission or made substantial improvement, they were followed closely for another 12 months.