![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 6 to 30 of 30. Go back in thread:
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
Posted by linkadge on July 10, 2006, at 16:47:46
In reply to Re: Level 3 Results of STAR*D announced, posted by ed_uk on July 10, 2006, at 14:27:45
Posted by River1924 on July 11, 2006, at 0:08:47
In reply to Re: Level 3 Results of STAR*D announced » SLS, posted by River1924 on July 10, 2006, at 12:38:04
This is a portion of McMan's Depression and Bipolar Weekly 8#8 (one can sign up for the great newletter at http://www.mcmanweb.com/)
" Four thousand patients with major depression, most of them with recurrent depression, were tried on Celexa under real world conditions. Forty-seven percent responded and 28 percent remitted, not exactly spectacular results but fairly predictable.
In round two, the 1,439 who did not fare well on Celexa and who elected to remain in the study were tried on either one of three antidepressants (Wellbutrin or Effexor or Zoloft) or one of two combinations (Celexa with Wellbutrin or Celexa with Buspar). The results were nothing to write home about (between a quarter and a third remitting) but were sufficiently encouraging to justify this Newsletter editorial comment:
"Clearly, STAR*D demonstrates the value in not quitting on antidepressant treatment, that if you keep at it long enough you are likely to find a med or combination of meds with your name on it."
Is my face red. The third round results have just been published in the July American Journal of Psychiatry, and the findings indicate that a serious rethinking about antidepressant treatment is in order. Serious as in Code Red, stop the presses, Defcon One, Junior go straight to your room right now.
In round three, 235 STAR*D patients who had not achieved satisfactory results were tried on flexible doses of either the novel action antidepressant Remeron or the old generation tricyclic nortryptyline for 12 weeks under real world conditions. Twelve percent of those on Remeron achieved remission (as measured on the HAM-D) vs one in five for those on nortriptyline. On the QIDS-SR, remission was eight and 12 percent, respectively for Remeron and nortriptyline.
The QIDS-SR response rates were equally dismal, 13 and 17 percent, respectively, for Remeron and nortryptyline.
The study authors did not attempt any positive spin. Instead, they noted:
"Contrary to previous efficacy trials in major depressive disorder, study results suggest that switching antidepressants … after two consecutive antidepressant medication trials have failed provides only a modest chance of producing remission in major depressive disorder."
So what went wrong? Was there something going on that STAR*D did not anticipate? Funny you should ask.
The Kraepelin Factor
When Newsletter 8#3 reported on the STAR*D second round results a few months ago, Frederick Goodwin MD, co-author (with Kay Jamison PhD) of "Manic-Depressive Illness" got back to me with this observation:"I noticed that the cohort they studied had a mean of six previous episodes; this means that they were relatively highly recurrent unipolar patients, which was included in Kraepelin's description of manic depressive illness (a term which is not synonymous with bipolar disorder)."
Those with recurrent depressions in the study also had an earlier age of onset than those with just one depressive episode (23 years vs 34 years).
To liberally interpret Dr Goodwin, there may have been patients in the study whose so-called unipolar depressions perhaps resembled bipolar depressions. Dr Goodwin, with S Nassir Ghaemi MD of Emory University, has proposed the new diagnosis of "Bipolar Spectrum Disorder" (BSD) that would acknowledge the clinical reality of many of these patients. One of the criteria for BSD would include brief recurrent episodes (more than five), early onset, and non-response to three antidepressants. A 2005 study found that 37 percent of those with unipolar disorder could conceivably be rediagnosed with BSD.
It is important to note that BSD also contains other criteria that would exclude many patients with highly recurrent depressions. The point is there may be a good many people who are not getting well because their unipolar depressions are not exactly conforming to whatever is meant by "uni."
In his correspondence to me, and in a talk at the recent American Psychiatric Association annual meeting in Toronto in late May, Dr Goodwin referred to early studies that found lithium had some effect for both bipolar depression and "cyclic" unipolar depression, and for preventing depression in these populations.
In his recent book "Why Am I Still Depressed?" Oregon psychiatrist Jim Phelps MD stresses the importance of "treating the cycle" for highly recurrent depressions (which also includes bipolar depressions) rather than the "symptom du jour." The emphasis is on getting the cycle under control, usually with a mood stabilizer (but also employing smart talking therapy and scrupulous life style management).
In other words, the way to go might be treating certain highly recurring unipolar depressions as if they were bipolar depressions. The catch is we haven’t enjoyed much success treating bipolar depression. The unfortunate consensus among the experts is that bringing a patient down from mania and stabilizing this individual is a piece of cake, by comparison.
Making Sense
Before we start generalizing, there are two round three trials yet to be reported - an antidepressant augmented with lithium and an antidepressant augmented with a thyroid supplement. Also, we are awaiting the cognitive therapy results from round two.Another point to consider: Although round two of STAR*D had six options, patients were only tried on one of them before being assigned to round three. Conceivably, a number of these patients may have fared better with another round two option.
Okay, now let’s generalize. So what have we learned from the third round of STAR*D? It appears that after two failed antidepressant trials, clinicians need to be rethinking their options. With a second trial the odds of success are somewhat less than the first, but third time out we are starting to look at the falling off the edge of the cliff phenomenon. The success rates drop off significantly.
The results should not be interpreted as two strikes and you’re out. It’s more like two strikes and let’s start rethinking. This is a crucial distinction. Going with a different antidepressant or antidepressant combo may be justified after two or even three or more failures.. But after the second failure, the clinician needs to be aware that he or she may have passed the point of diminishing returns.
Should the patient be informed of the situation? On one hand the patient has a right to know. On the other, the bitter truth may act as a reverse placebo.
At this stage, the clinician needs to be looking far more closely at the patient’s depression. Highly recurrent? Early onset? Family history of bipolar? First-degree relative with bipolar? Mixed states? Co-occurring illnesses? Personality issues? Arguably, this should have happened at the very beginning of treatment, but better late than never.
So will round four give us some answers we are looking for? Unfortunately, round four offers up yet more of the same (a switch to an MAOI or a switch to a Remeron-Effexor combo). Moreover, we are looking at a likely pool of about 100 patients – way down from the original 4,000 – so these results will probably be less than authoritative.
End of the Road for STAR*D?
It’s easy to say STAR*D should have included various lithium, Lamictal, and Seroquel options in rounds two and three, but we know a lot more now than back seven years ago when STAR*D was on the drawing board. One thing we learned from round three is there is a crying need for fresh trials with mood stabilizer options, but we won’t learn anything more if the NIMH pulls the plug on STAR*D.Another reason to keep STAR*D going is if the project had been funded by a pharmaceutical company rather than the NIMH the results may never have been published, or we may have seen different results based on cooked statistics. Our health and well-being is way too important to rely solely on drug companies for information.
The infrastructure for STAR*D is already in place – 41 treatment centers throughout the US, trained personnel, protocols, data collection, institutional wisdom, everything. This is no time to wrap up the program. Fresh funding, fresh patients, new insights, new treatment options – let’s get started.
Final Word
The people who put together STAR*D felt very strongly that remission rather than response should be the goal of antidepressant treatment, and used this much higher standard as the criterion for success in their trials. But we know antidepressants leave a lot to be desired, and that true recovery typically involves active measures on the part of the patient, as well, such as good lifestyle regimens, coping techniques, support, effective stress management, and cognitive skills.The paradox: Perhaps if we don’t expect much of our antidepressant, we can get much better results.
Posted by cecilia on July 11, 2006, at 2:55:31
In reply to Re: Level 3 Results of STAR*D announced, posted by ed_uk on July 10, 2006, at 14:27:45
> 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.
>
> EdIt's bizarre, but this is standard doctor talk. Even for babies. Doctors will say "We attempted to wean Baby Y off his oxygen but he flunked." Maybe it's the super competitive nature of medical school and pre-med that make doctors see everything this way. Cecilia
Posted by cecilia on July 11, 2006, at 3:07:42
In reply to Re: Level 3 Results of STAR*D announced :-) » cecilia, posted by SLS on July 10, 2006, at 5:00:39
Thanks, Scott. I felt bad that you felt insulted by what I'd said before. I hope you find the right med soon. I think you've tried even more than I have. I know you once had a combo that worked, so that gives you reason for hope. It's hard for me to be optimistic because I've never had anything work. Cecilia
Posted by linkadge on July 11, 2006, at 16:44:47
In reply to a very long but worthwhile STAR*D article, posted by River1924 on July 11, 2006, at 0:08:47
"One of the criteria for BSD would include brief recurrent episodes (more than five), early onset, and non-response to three antidepressants."
I think that is complete nonsense. The doctors are still working under the false impression that they they have all the necessary tools, and that the tools work fine.
If a unipolar person doens't respond to an antidepressant why wouldn't one simply think "well perhaps our antidepressants aren't that good", or "we havn't hit the right target". All of a suddden however, just because a patient doesn't respond to an antidepressant, he must be bipolar.
If a cancer patient doesn't respond to cancer treatment, does that all of a sudden mean that he never really had cancer ?
Early onset? Is it not possable to have a depressive personality/disposition from an early age? Why on earth does that indicate bipolar?
Linkadge
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.