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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 30. This is the beginning of the thread.
Posted by Jat on July 4, 2006, at 8:42:28
Hey Everyone,
So in level 3, patients got switched to either remeron or nortriptyline. Approximately 16% of patients had a remission of their depression. Here is the link ...
www.usatoday.com/news/health/2006-07-01-depression-drug_x.htm
I am not sure what the other portion of level 3 demonstrated .... augmentation with either lithium or thyroid.
Overall .... at the end of level 3, about 60% of patient had remission .... 40% of patient still suffering despite state of art treatment.
Jat
Posted by River1924 on July 4, 2006, at 13:58:34
In reply to Level 3 Results of STAR*D announced, posted by Jat on July 4, 2006, at 8:42:28
I saw the article at http://www.medicalnewstoday.com/medicalnews.php?newsid=46265&nfid=nl
It seems summed in this section:
“The results of STAR*D continue to be sobering. By the third wave of the study, the rate of remission continues to be quite low, which underscores the persistence of depression and its resistance to current treatments,” states Robert Freedman, M.D., AJP editor-in-chief.
STAR*D was designed to parallel real-world practice. After the failure of the first one or two medications, often the clinician tries an antidepressant from a different pharmacological class. The antidepressants in Level 3 had pharmacological actions different from those in the previous levels and from each other.
“This finding is particularly relevant to clinical practice because it is based on typical patients,” said Darrel A. Regier, M.D., M.P.H., director of the APA's Division of Research.
Posted by Phillipa on July 4, 2006, at 15:32:54
In reply to Re: STAR*D depressing depression study, posted by River1924 on July 4, 2006, at 13:58:34
Does that mean three antidepessants at the same time? Love Phillipa
Posted by med_empowered on July 4, 2006, at 22:13:36
In reply to Re: STAR*D depressing depression study » River1924, posted by Phillipa on July 4, 2006, at 15:32:54
I don' know if this study shows how "persistent" depression is so much as it underscores the woefully inadequate options patients are given in usual practice.
I think it kind of proves what we patients have known for a long, long time--it isn't so much that we're "treatment resistant" as it is that the treatments leave much to be desired.
Posted by cecilia on July 5, 2006, at 3:40:52
In reply to Level 3 Results of STAR*D announced, posted by Jat on July 4, 2006, at 8:42:28
Considering how many of us have failed far far more meds than the few in this study, it is discouraging. It makes me mad how books and articles still talk all the time about how "treatable" depression is. I read an article once by a psychiatrist writing about the assisted suicide law in Oregon for terminally ill patients, he wrote about how this shouldn't be allowed because these patients, even if terminally ill, were depressed and depression was treatable. Like what are the odds that these patients are going to find the right treatment before they die? I think most pdocs have a VERY distorted idea of how many people actually improve with meds because the improvers keep coming back to get their prescriptions refilled, the others don't.
Posted by med_empowered on July 6, 2006, at 13:47:35
In reply to Re: Level 3 Results of STAR*D announced, posted by cecilia on July 5, 2006, at 3:40:52
yeah...ive noticed that with shrinks. They seem to have this idea that "the drugs work--PERIOD." and they don't get that: some people require combos or different meds (example: provigil instead of prozac) and that some people's conditions just aren't responding--and it isn't their fault (I hate it when treatment failures are explained away based on alleged "non-compliance" or, even worse, when shrinks blame some previously undiagnosed personality disorder).
Assisted suicide is just sad--I personally think it should be legal, but we should really focus more on effective pain management, so that way people can live out their last days comfortably and not beg for a big bottle of Seconal to end their suffering. I'd definitely take issue with a shrink diagnosing patients he/she had never even seen with depression and then dismissing their problems as "just depression". Interestingly, from what I understand, psychiatrists have a relatively high rate of suicide themselves.
SO..yeah...the STAR study is sobering. Unfortunately, the spin machines will probably go into full gear to show that "70% of patients can achieve remission," even if it take many drug trials to get to remission (and even if this remission rate isn't compared to placebo, psychotherapy, or non-intervention). Also, I imagine when all the data is hashed, some cases of non-response will be chalked up to non-compliance or a personality disorder or perhaps some sort of misdiagnosis--the patient had soft bipolar, not unipolar depression, or OCD features, or something like that. THere's always a loop hole to make bad numbers look better, which in the end helps shrinks and drug companies, but does an absolute disservice to people living in misery.
Oh well.
Posted by med_empowered on July 6, 2006, at 13:50:52
In reply to Re: Level 3 Results of STAR*D announced, posted by med_empowered on July 6, 2006, at 13:47:35
high rates of suicide among psychiatrists:
Posted by cecilia on July 8, 2006, at 6:59:47
In reply to Re: Level 3 Results of STAR*D announced, posted by med_empowered on July 6, 2006, at 13:47:35
Well realistically, a lot of treatment resistant people do have personality disorders, but we also have Major Depression. Some times it's which came 1st the chicken or the egg. Sometimes the meds do work for people with personality disorders. Elizabeth Wurtzell's "Prozac Nation" classic borderline personality disorder, but meds worked for her. Of course meds are never going to solve all our problems, personality disorder or not, we all have issues. But many doctors see treatment resistant patients as personality disordered by definition. The very statement "treatment resistant" is derogatory, implying that the patient is choosing not to respond. Do they use this phrase in oncology for patients who fail to respond to chemo? I don't know, but somehow I doubt it. Cecilia
Posted by SLS on July 8, 2006, at 7:16:23
In reply to Level 3 Results of STAR*D announced Med-Empowered, posted by cecilia on July 8, 2006, at 6:59:47
> Well realistically, a lot of treatment resistant people do have personality disorders,
What would you estimate to be the percentage?
> Of course meds are never going to solve all our problems, personality disorder or not, we all have issues.
I see a lot of people writing this here on Psycho-Babble, and I must say that I feel insulted that someone should assume this of me. Why must I have issues just because I have a biological brain disorder?
> But many doctors see treatment resistant patients as personality disordered by definition.
I have never been given this impression by any of my doctors in my 25 years of failed treatments. I have never heard of this axiom.
> The very statement "treatment resistant" is derogatory,
I have never heard this.
> implying that the patient is choosing not to respond.
I am fortunate not to have been made to feel this way by my doctors. I know better.
I don't mean to be adversarial, but my experience with psychiatry does not match yours - fortunately. I hope I am not in the minority. It might depend upon from what generation the practitioner learned his trade.
- Scott
Posted by SLS on July 8, 2006, at 7:30:26
In reply to Re: STAR*D depressing depression study, posted by med_empowered on July 4, 2006, at 22:13:36
> I don' know if this study shows how "persistent" depression is so much as it underscores the woefully inadequate options patients are given in usual practice.
>
> I think it kind of proves what we patients have known for a long, long time--it isn't so much that we're "treatment resistant" as it is that the treatments leave much to be desired.I guess that's the point of the project. It is an attempt to establish a foundation for an evidence-based algorithm for treating mood disorders. The treatments chosen so far are obviously austere and do not reflect the creativity in the treatment regimes we see used regularly on Psycho-Babble. The success rate practicable with the drugs currently available is probably greater than that they have thusfar managed to glean from their simplistic treatment strategies.
- Scott
Posted by linkadge on July 8, 2006, at 18:11:36
In reply to Re: Level 3 Results of STAR*D announced, posted by cecilia on July 5, 2006, at 3:40:52
I agree. My grandfather was dying of cancer, and they put him on TCA's, which didn't do much for him.
Linkadge
Posted by linkadge on July 8, 2006, at 18:13:35
In reply to interesting article..., posted by med_empowered on July 6, 2006, at 13:50:52
They must know things that we don't.
They either know that the treatments are not that effective, or they know that they're not that safe. (thats my opinion) I suppose they don't feel like they have too many options.
Linkadge
Posted by linkadge on July 8, 2006, at 18:16:18
In reply to Level 3 Results of STAR*D announced Med-Empowered, posted by cecilia on July 8, 2006, at 6:59:47
Most of the current treatments are just working on the same basic things. There isn't much variety. If you don't respond to a drug that boosts serotonin, then you really only have one option, and that is a medication that boosts norepinephrine.
The MAOI's are really the only medication that has appreciable effect on dopamine.
There just needs to be more variety. How many more S/NRI's can one person try?Linakdge
Posted by linkadge on July 8, 2006, at 18:20:59
In reply to Re: interesting article... » med_empowered, posted by linkadge on July 8, 2006, at 18:13:35
I've been on over 10 antidepressants, alone, and in strange combinations. I wonder what likelyhood of sucess is now.
I do agree, doctors are full of their treatments, or at least thats the way they are taught to present themselves.
I suppose by the third drug one has likely fully filtered out the placebo responders.
Linkadge
Posted by ed_uk on July 8, 2006, at 18:36:40
In reply to Re: interesting article..., posted by linkadge on July 8, 2006, at 18:20:59
>I suppose by the third drug one has likely fully filtered out the placebo responders
That's what I was thinking Link.
Ed
Posted by cecilia on July 8, 2006, at 21:03:49
In reply to Re: Level 3 Results of STAR*D announced Med-Empow » cecilia, posted by SLS on July 8, 2006, at 7:16:23
Sorry, SLS, I didn't mean to be insulting. I meant that, in my opinion, 100% of the population of the world has "issues", not just 100% of the Psycho-Babble population. No one had a perfect childhood. My experiences with both psychiatry and therapy have indeed been bad, and you're fortunate to have had better experiences. I think many pdocs do assume that someone who has failed therapy and multiple meds is hopeless, whether due to a personality disorder, biological issues or a combination. In my own case, it's probably a combination, I can't speak for anybody else. You've been very supportive of everybody here and I'm sorry if what I said came out wrong and hurt you. A hundred years from now, if the world hasn't blown itself to bits by then, scientists will hopefully have figured out the human brain and treatment resistant depression will no longer exist. Unfortunately, it's not likely to happen in my lifetime. Cecilia
Posted by SLS on July 9, 2006, at 7:23:29
In reply to Re: Level 3 Results of STAR*D announced- SLS, posted by cecilia on July 8, 2006, at 21:03:49
> Sorry, SLS, I didn't mean to be insulting. I meant that, in my opinion, 100% of the population of the world has "issues",
Now, you see, I just don't feel that making sweeping statements like that are productive or supportive. I don't need anyone telling me that I have some psychological pathologies that remain unresolved since childhood that are responsible for some sort of emotional discontent that persists in adulthood. It simply isn't true. Some of us do manage to run the gauntlet successfully.
> No one had a perfect childhood.
Perfection is not necessary for happiness. Actually, I doubt it can be attained except for in its absence.
I realize that it is not your intent to be insulting as it is not mine to be beligerent. However, I do feel quite strongly about this issue.
- Scott
Posted by linkadge on July 9, 2006, at 15:35:31
In reply to Re: Level 3 Results of STAR*D announced » cecilia, posted by SLS on July 9, 2006, at 7:23:29
I don't want to be mean in any way, and I will appologise now for the comment if it offends, but I tend to agree with cecelia. I do find it hard to believe that certain behaviors don't either contribute to the cause, or contribute to the prolongation of suffering in mental illnesses.
Not always saying these behvaviors are or will ever be identifyable.
Everyone can look back in their past and wonder if they had done something differently how things might have been better today. I don't think you'd be human if you havn't done that. Just that act, is due to a small fraction of us that believes that behavior does indeed play a role.
For myself, it has simply been "wanting". There have been times when I was virtually "ok" and in remission, but I wanted more, and for that, I lost more.
Linkadge
Posted by cecilia on July 9, 2006, at 20:12:28
In reply to Re: Level 3 Results of STAR*D announced » cecilia, posted by SLS on July 9, 2006, at 7:23:29
Well, it's probably something that's on a continuum. For some people, and you're probably one, Scott, depression is 100% biological. For others, it may be 100% psychological. For most people, they're probably somewhere on the continuum between biological and psychological. Doctors and T's are likely to decide where on the continuum someone falls based primarily on their own theoretical leanings. The other part of course, is that it's not merely X causes Y, Y also causes X. Long term depression, even if 100% biological in origin, will, in many cases, change someones's view of the world. And bad experiences such as abuse have been shown to cause physical changes in the brain. Cecilia
Posted by linkadge on July 9, 2006, at 20:51:43
In reply to Re: Level 3 Results of STAR*D announced, posted by cecilia on July 9, 2006, at 20:12:28
Stressfull life events often can initiate depression in the genetically susceptable. Most people I know had their fist episode of depression during a time of significant emotional, or psychosocial stress.
Linkadge
Posted by SLS on July 10, 2006, at 5:00:39
In reply to Re: Level 3 Results of STAR*D announced, posted by cecilia on July 9, 2006, at 20:12:28
> Well, it's probably something that's on a continuum. For some people, and you're probably one, Scott, depression is 100% biological. For others, it may be 100% psychological. For most people, they're probably somewhere on the continuum between biological and psychological. Doctors and T's are likely to decide where on the continuum someone falls based primarily on their own theoretical leanings. The other part of course, is that it's not merely X causes Y, Y also causes X. Long term depression, even if 100% biological in origin, will, in many cases, change someones's view of the world. And bad experiences such as abuse have been shown to cause physical changes in the brain. Cecilia
:-)
That is one of the most cogent, concise, and accurate depictions of the phenomenology of affective disorders I have yet seen! Kudos.
- Scott
Posted by SLS on July 10, 2006, at 5:21:26
In reply to Re: Level 3 Results of STAR*D announced, posted by linkadge on July 9, 2006, at 20:51:43
> Stressfull life events often can initiate depression in the genetically susceptable. Most people I know had their fist episode of depression during a time of significant emotional, or psychosocial stress.
>
> Linkadge
"The brain determines the mind as the mind sculpts the brain."
- Scott
Posted by River1924 on July 10, 2006, at 12:38:04
In reply to Re: Level 3 Results of STAR*D announced » linkadge, posted by SLS on July 10, 2006, at 5:21:26
Scott,
To go back to a far earlier point, the phrase "treatment resistant depression" seems to imply some fault on the patient. I think, "treatment deficient depression" would be more accurate. Or "unresolved depression." For me, when I'm depressed, it is my depression. (Unlike an infection, which I would not call "my" infection..."; depression is subjective and intimate.) I know if I am completely logical, the phrase treatment resistant depression isn't supposed to be a judgement but when I was very depressed, I took it that way. I didn't feel depressed. I was depressed. Depression was me. I felt defective and the phrase "treatment resistant" only emphasized (to me) that I was at fault.
Plus, it takes a very empathetic and astute and self-aware doctor not take it personally if his patient doesn't respond to treatment. The doc may be unable to help and feel frustrated and it is very easy to just start pulling away emotionally from the patient. To me that is human nature and really can't be helped. But, when I am depressed, I pick that up and "assume" his frustration indicates that I am lazy, or unmotivated, etc etc...
Whatever. River.
Although almost ten years old, I think this book might be relevant to this discussion."I.D.: How Heredity and Experience Make You Who You Are (Hardcover)"
by Winifred Gallagher
Posted by ed_uk on July 10, 2006, at 14:27:45
In reply to Re: Level 3 Results of STAR*D announced » SLS, posted by River1924 on July 10, 2006, at 12:38:04
It's interesting how pdocs often say.....
Mr. X failed to respond to Effexor
rather than.......
Effexor failed to treat Mr. X's depression
It's almost as if they're saying that it was the patient who failed rather than the drug.
Ed
Posted by linkadge on July 10, 2006, at 16:46:34
In reply to Re: Level 3 Results of STAR*D announced » linkadge, posted by SLS on July 10, 2006, at 5:21:26
Well in that case, even if the brain isn't affected by the outside environment, the mind sure is.
It makes me feel special to think that my illness is due to some loftier genetic abnormality, but I think it comes down the the simple principle, everyone has their breaking point.
You can induce depression in any mouse. Just stress it enough. Oh sure, some may have a sligtly lower breaking point, and lable that as you may, but each still has it. Each will give up at a point.
Were the mice chemically imballenced? Stress can induce detectable chemical imballence.
We have yet to find a single mouse that becomes depressed if its treated properly.
Believe what you will.
Linkadge
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