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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 65 to 89 of 97. Go back in thread:
Posted by rskontos on August 29, 2007, at 10:05:46
In reply to To the people who don't believe in biological dep., posted by Enigma on August 29, 2007, at 9:26:52
Why are people trying to blast someone's view that his depression is biological based versus chemical based. It is going back to the nature vs nuture argument. Aren't we here to support each other or to aruge our knowlege over someone's else's. I came to this board to find support but so far I see more debate over who knows more. Knowledge is good to share but not to hurt people who far as I know are already in a bad place for the most part. I know the day I came here I was in a dark place. I spoke up, which for me in the place it was hard, and all I received was challenges on my knowledge. Which has come from the internet and the various doctors I have in my life. I don't claim to know everything. I, too, used what knowledge I have gleemed from literature I have researched, I sort out the good, the bad, and the ugly, and then have to decided what applies. I try to share what I think is helpful and what has worked for me only to help someone else in the same dark place I struggle daily to live within. I hope one day to emerge victoriously but I realize I need help and I need help from others that share that walk. But here, I am not getting the sense we are all in this together for the same reasons. It seems some want to appear as the most knowledgable or maybe it helps thinking it is a chemical thing and drugs are the best, I don't know what the motivation is. I only know that it seems like an honest debate isn't going on. It seems Enigma stated his case, and everyone is arguing with him and down playing how he feels which is legit. I think I will move on, to a safer place where my feeling are considered above knowledge. Good luck to all.
Posted by gardenergirl on August 29, 2007, at 10:38:33
In reply to Re: To the people who don't believe in biological dep., posted by rskontos on August 29, 2007, at 10:05:46
I don't believe that "bashing" someone's belief system about their depression or other illness is likely to be helpful to them. However, if someone is taking a unilateral approach to treatment, i.e. either medical intervention or psychological or alternative, etc., AND if this approach is not working, it might be helpful to talk to them about other ways of thinking about depression and treatment. If someone is continuing to "do the same thing" even though it's not working and they expect different results, I think they are more likely to be disappointed. But trying a different approach, or adding a different approach is making a change that could lead to a different result. It's been shown in the literature that a combination of medical plus psychological interventions often is more effective in treating many types of depression than either one alone. (Sorry for general language and no cites...in a hurry here.)
So encouraging someone to think about cause and treatment from a different perspective, while respecting their beliefs, can be helpful and educational, imo. But that last part is crucial--respect.
gg, who hasn't read the whole thread, so if this is a redux of someone else's post, I apologize.
Posted by Deputy 10derheart on August 29, 2007, at 17:08:05
In reply to Re: To the people who don't believe in biological dep., posted by rskontos on August 29, 2007, at 10:05:46
>>Why are people trying to blast someone's view
>>everyone is arguing with him and down playing how he feelsPlease don't post anything that could lead others to feel accused or put down.
If you or others have questions about this or about posting policies in general, or are interested in alternative ways of expressing yourself, please see the FAQ: http://www.dr-bob.org/babble/faq.html#civil
Follow-ups regarding these issues should be directed to Admin and should of course be civil. Dr. Bob has oversight over deputy decisions, and he may choose a different action.
>>I think I will move on, to a safer place
I'm sorry Babble doesn't feel safe to you. I understand the need to move on, but maybe at some point you'll reconsider? The idea is to allow and value everyone's POV, as long as it's expressed within the civility guidelines. Sometimes, we have 'bumps' along that path, but maybe it could become smoother again? Good luck to you, too, whatever you decide.
- 10derHeart, acting as deputy for Dr. Bob
Posted by Deputy 10derheart on August 29, 2007, at 17:08:12
In reply to To the people who don't believe in biological dep., posted by Enigma on August 29, 2007, at 9:26:52
>>they spew their BS opinions about it.
>>Having to listen to BS is another.
>>I didn't think even you could be so ignorant.Please don't post anything that could lead others to feel accused or put down.
If you or others have questions about this or about posting policies in general, or are interested in alternative ways of expressing yourself, please see the FAQ: http://www.dr-bob.org/babble/faq.html#civil
Follow-ups regarding these issues should be directed to Admin and should of course be civil. Dr. Bob has oversight over deputy decisions, and he may choose a different action.
10derHeart, acting as deputy for Dr. Bob
Posted by Deputy 10derheart on August 29, 2007, at 17:13:13
In reply to Re: To the people who don't believe in biological, posted by gardenergirl on August 29, 2007, at 10:38:33
Posted by linkadge on August 29, 2007, at 20:44:57
In reply to Re: Still no cure for my depression - tried everyt, posted by jhj on August 29, 2007, at 0:29:57
>I have social anxiety,GAD and depression since >childhood.And i do not recall any traumatic or >stressful event taking place in my life till yet.
k
>As far as animal models are concerned,they can >not be taken seriously.I have seen thousand >things being investigated and drugs found using >mice and rats.But,It does not lead to anything >in the end.
Actually, it leads to a lot in the end. %99 of the psychiatric drugs we take today were likely originally identified for their activities in rodents.
>You mean to say what happens to rats is more >believable then my own case? If i had been >normal in childhood,i would have easily said my >childhood was as good as anyone.
No, what I said is not being taken correctly. I did not say that some depression may not have a biological origin, I am just saying that as of this date, we only really have leads, or hints as to specific biochemical abnormalities.
>No stressfull events but still terrible mental >problems.Can yot tell me what your animal model >suggests in my case "conclusively"? Thanks.
Take obesity for example. I am sure there are some people who are obese who have absolutely no controll over their illness (ie purely genetic). We do know, however, that obesity is on the rise, so, unless this bad gene is multiplying at an exponential rate, one must consider the influence of other factors.
As of this date, no one gene has been identified as being responsable for depression, nor has any one diagnostic marker been definitivly outlined. While I am sure, that some people's depression may be solely due to a bad gene, I would argue that for a large number of with depression, environmental factors play a role in the progression of their disease.
Environmental factors needn't always be "stress". Just as environemntal toxins can cause selective dopaminergic neurotoxicity, perhaps some sort of serotonergic neurotoxin is the cause of an individuals depression. Nutritional imbalences may also be at the heart of certain depressive states.
For some people, considering their disease as a purely genetic one perhaps helps relive some of the guilt associated with the depressive state.
In the end though, there is little proof than any one person's depression is a purely genetic phenomina.
Linkadge
Posted by linkadge on August 29, 2007, at 21:06:26
In reply to To the people who don't believe in biological dep., posted by Enigma on August 29, 2007, at 9:26:52
>These took me all of 5 minutes to find on the >web:
You can find a lot of biased information in a very short period of time.
Again, I never said that depression may not be of a purely biological origin for some individuals, but there is little proof that the majority of depression is biological.
>Whatever its cause, depression is not just a >state of mind. It is related to physical changes >in the brain, and connected to an imbalance of a >type of chemical that carries signals in your >brain and nerves. These chemicals are called >neurotransmitters.Petting a dog will increase your serotonin levels.
>This is what we DO know about bipolar disorder:
>* Special chemicals in the brain may be >involved. If the levels of these chemicals are >out of balance, it may be harder for brain cells >to work as they should.They can only really say "may".
>* Also, certain parts of the brain may have a >different size or shape in people with bipolar >disorder. The changes could be a cause or >symptom of the illness.
Again, they can only say "may". They also say that brain changes could be a *cause* or a *result* of bipolar disorder.
>Myth: Bipolar symptoms are always triggered by >some event.
>Fact: Symptoms of bipolar disorder are often >triggered by a stressful event, but not always. >Sometimes mood swings happen without any obvious >triggers.Again, they are not discounting environmental influences.
>I did find 2 other sites that tried to say >depression and such was NOT caused by chemical >imbalances.. BUT, GUESS WHAT? They were SELLING >SOMETHING. Yep, propaganda so they could sell >their books and audio tape sets. The sites I >listed aren't selling a thing.
To be blunt, everbody is trying to sell something. There is a profession called psychiatry, whereby the livelyhood of the professional is directly proportional to the number of ill patients he or she has.
>I have bipolar disorder. Like it may or may not >say above, it's LIFELONG illness. So, tree >hugging, going to live with monks for a year, >isn't going to cure me of anything.
Why do people go from one extreme to the other?? (Besides being bipolar?). Its notnecessarily about tree hugging, or joing a church, or getting exercised, or living with monks, etc. Recognizing the environmental factors that influences the disease can help a patient to make the best recovery.
I may still take my medication, but if I recognize that too much stress in school is making my depression worse, for example, then I will try and cut back. Nobody lives in a vaccume.
>I was fine Sunday, and in bed Monday and >Tuesday. I hope people talking about MY disorder >actually SUFFER from my disorder before they >spew their BS opinions about it. Having a >different opinion is one thing. Having to listen >to BS is another.
Its not just one opinion. Some of the most respected molecular biologists who are currently working on reasearch into the etiology of bipolar admit that the recognition of environemental factors is crutial to recover. Dr. Manjii, for instance, is currently trying to uncover the molecular action of the mood stabilizers essentially says how important it is for bipolars to reduce stress on acount of the way that stress can increase PKC, cortisol, glutamate, etc. He considers bipolar disorder to be a disorder of loss of cellular resilliance, whereby there is a reduced cellular tollerance for environmental stress. So, yes there are genetic influences, and there are environmental influences.
>I'm gonna go hug a tree now, and maybe do deep >breathing exercises in the woods, and I'm sure >that will clear me right up. Yeah, that's >sarcasm.
To close your mind to the possable ways that environmental factors can influence your illness may lead to a worse outcome. This isn't about "tree hugging", this is about knowing how to go about your day in a way that keeps yourself sane. Its stuff you're likely doing already.
Linkadge
Posted by linkadge on August 29, 2007, at 21:11:07
In reply to Re: To the people who don't believe in biological dep., posted by rskontos on August 29, 2007, at 9:50:10
If you want to believe your mood disoder is a result of this or that, then it is your right.
All I am saying, is that some people adopt a mindset whereby their disease is necessarily %100 biological, and therefore completely discount all other possable influences.
This is a grave mistake (IMHO), and may lead to a worse outcome.
Just like how my Dad says how his high cholesterol is genetic, and pops his cholesterol pill on the couch before preceeding to wolf down t-bone steak, fries, potatoe with sour cream, coke, and sausage for desert.
He has closed his mind to other influences, and therefore he will likely suffer.
All I am saying is keep your mind open.
Like Dr. Peter Kramer suggested, you acutally do need to "Listen to Prozac".
Linkadge
Posted by jhj on August 30, 2007, at 6:31:55
In reply to Re: Still no cure for my depression - tried everyt, posted by linkadge on August 29, 2007, at 20:44:57
Actually, it leads to a lot in the end. %99 of the psychiatric drugs we take today were likely originally identified for their activities in rodents.99% of drugs today were "likely" originally identified.I think you yourself seem to be in doubt about this 99% figure.Anyway,even if i believe that is true,then no wonder why none of these drugs has any beneficial effect on me despite trying atleast 20 of them in years.
I did not say that some depression may not have a biological origin, I am just saying that as of this date, we only really have leads, or hints as to specific biochemical abnormalities.
surprising.I am living human being and i am saying that my problems started in childhood despite having good childhood,leaving in healthy environment,being sound financially and eating good food,i have developed these problems.In fact,when i started understand things when i was around 5-6 years old,one of the first things i understood was that i am abnormal kid and something is wrong with me and it has proved to be the fact.I do not know if this according to you is only hint but in my opinion it is conclusive proof that it was biological.
As of this date, no one gene has been identified as being responsable for depression, nor has any one diagnostic marker been definitivly outlined. While I am sure, that some people's depression may be solely due to a bad gene, I would argue that for a large number of with depression, environmental factors play a role in the progression of their disease.Scientist have identified many genes responsible for depression.But,it is not caused by one gene.It is due to the complex effect of verious genes each one play small part in the depression.Human brain is very complicated things if scientists have not been able to understand the mechanism and continue to experiment on rodents then it is their problem.I was not raised amidst any environmental toxicity or did not think i had nutritionally unbalance diet.I have not seen anybody else from my area having the same problem.I have seen some tragic incident after these problems were there but,they have not worsened my problems in any way.It is same as it was before years?no more,no less.So,how can it be said that illness has progressed?
For some people, considering their disease as a purely genetic one perhaps helps relive some of the guilt associated with the depressive state.
True but partially.It is not some of the "guilt" but complete guilt.In short,whatever has happened to me or happening to me is purely because of biological reasons and neither i nor my family nor my immediate environment has any role to play whatsoever.Thanks.
Posted by jhj on August 30, 2007, at 6:39:54
In reply to Re: To the people who don't believe in biological dep., posted by linkadge on August 29, 2007, at 21:11:07
Keep mind open to only convincing things.Because one is always bombarded with some useful and many unuseful information and we see clearly that environmental factors are not affacting us we should filter it out as junk information and should not overburdan our mind.
Posted by gardenergirl on August 30, 2007, at 9:54:46
In reply to thanks for this post, gg (nm) » gardenergirl, posted by Deputy 10derheart on August 29, 2007, at 17:13:13
Posted by linkadge on August 31, 2007, at 13:40:36
In reply to Re: Still no cure for my depression - tried everyt, posted by jhj on August 30, 2007, at 6:31:55
>surprising.I am living human being and i am >saying that my problems started in childhood >despite having good childhood,leaving in healthy >environment,being sound financially and eating >good food,i have developed these problems.In >fact,when i started understand things when i was >around 5-6 years old,one of the first things i >understood was that i am abnormal kid and >something is wrong with me and it has proved to >be the fact.I do not know if this according to >you is only hint but in my opinion it is >conclusive proof that it was biological.
I'm not trying to convince anybody of anything they don't want to believe. All I am saying is that some people can become convinced of things that there is really little proof of.
An example is when people come on the board saying things like "I am dopamine deficiant". I am sure it all seems justified in their mind.
>Scientist have identified many genes responsible >for depression.
No they havn't. They have found genes that are associated with depression in certain persons. They find genes that are of higher frequency in patients with depression. This doesn't mean that the gene is responsable, or that the gene has any predictive validity of illness. There is a lot of genetic research compilations on www.neurotransmitter.net. But for every genetic association, you're likely to find an equally well designed study showing no association.
>But,it is not caused by one gene.It is due to >the complex effect of verious genes each one >play small part in the depression.That is a theory yes.
>I was not raised amidst any environmental >toxicity or did not think i had nutritionally >unbalance diet.
How is the level of stress in your life? Do you work in a stressfull profession?
>True but partially.It is not some of the "guilt" >but complete guilt.In short,whatever has >happened to me or happening to me is purely >because of biological reasons and neither i nor >my family nor my immediate environment has any >role to play whatsoever.Thanks.
Thats fine. I am just arguing that to close the door on certain possabilities is not really all that benificial in the long run. To say that there might be environmental influences on your mood is not to accuse you of anything. Do you notice that your mood is worse during times of stress? Do you notice that your mood changes with the seasons or duration of daylight? Do you notice that your mood fluctuates with varying levels of exercise etc etc.
Even my mother, who is harcore on medications, and genetic causes, still knows that a warm bath can help relax her. Thats what I am talking about.
Linkadge
Posted by linkadge on August 31, 2007, at 13:47:45
In reply to Re: To the people who don't believe in biological dep., posted by jhj on August 30, 2007, at 6:39:54
>Keep mind open to only convincing things.Because >one is always bombarded with some useful and >many unuseful information and we see clearly >that environmental factors are not affacting us >we should filter it out as junk information and >should not overburdan our mind.
But why is what psychiatry says so convincing? They have a bunch of medications that were essentially discovered by accident and generally defy most studies designed to cross examine potential mechanisms. The medications can fail some 30-60% of the time or more, and do not always lead to remission. In addition, the majority of all published clinical trials on antidepressants fail to destinguish between active drug and placebo.
I'm not saying don't give anything a try, I am just saying that that the majority of uneducated faith in psychiatry and its cures is probably unfounded.
I am sure too, that there have been a number of cures that have been thrown in the "junk" pile on account of an effort to bolster public opinion of a particular point of view.
Linkadge
Posted by Existentialist on August 31, 2007, at 20:07:44
In reply to Re: To the people who don't believe in biological dep. » jhj, posted by linkadge on August 31, 2007, at 13:47:45
Hi enigma,
I'm trying to get a better idea of what exactly depression is like. Can you describe to me how you see the world, how you feel, and what it's like for, what is your experience of life like?
Posted by jhj on September 1, 2007, at 8:11:23
In reply to Re: To the people who don't believe in biological dep. » jhj, posted by linkadge on August 31, 2007, at 13:47:45
But why is what psychiatry says so convincing? They have a bunch of medications that were essentially discovered by accident and generally defy most studies designed to cross examine potential mechanisms. The medications can fail some 30-60% of the time or more, and do not always lead to remission. In addition, the majority of all published clinical trials on antidepressants fail to destinguish between active drug and placebo.
There was a major study in real environment starD done by NIMH.And after four phases 2/3 patients reported remission(not improvement).Majority is very subjective things.There are countless studies showing efficacy of all the drugs and advantage over placebo.
I am sure too, that there have been a number of cures that have been thrown in the "junk" pile on account of an effort to bolster public opinion of a particular point of view.
Well,i come from the country(India) where psychiatry is discouraged and not bolstered.India has taught alternative therapies like yoga,meditation etc. to the world and they are always preferred over medicines in India.Not that i have not tried anything.I have tried CBT too.But it is safe to say that CBT,yoga,meditation are absolute piece of rubbish that does not work. You people have started practicing yoga,meditation now.Out buddhist monks and hindu saints have been doing that for thousands of years and i have seen that almost every person in India does that.But,i have not said anything very positive about it even from healthy person except small reduction in stress and minor relaxation.
Posted by jhj on September 1, 2007, at 8:46:05
In reply to Re: Still no cure for my depression - tried everyt, posted by linkadge on August 31, 2007, at 13:40:36
No they havn't. They have found genes that are associated with depression in certain persons. They find genes that are of higher frequency in patients with depression. This doesn't mean that the gene is responsable, or that the gene has any predictive validity of illness. There is a lot of genetic research compilations on www.neurotransmitter.net. But for every genetic association, you're likely to find an equally well designed study showing no association.Even those diseases which are widely believed to be genetically based like diabetes,heart attack etc can not be predicted.No genetic test is available for these diseases too. The reason is many genes combine to lead to those diseases and we have very small information about gene melfunctioning in human being.In fact,genetics is very new subject and if you see two years all baby walking slowly,it does not indicate that he or she is only going to walk slowly for ever even after growing up.In fact,it is the other way around.It can be reasonably safe to predict that child will be able to walk fast and even run in the future.
That is a theory yes.
It is not a theory.It is common sense.One does not need to be rocket scientist to understand that.it is self explanatory truism.
How is the level of stress in your life? Do you work in a stressfull profession?
There is no stress at all in my life.My job does not require me to be stressful and my organisation is very liberal and i have got promotions when i did not expect those.I have got sufficient money now where i can even afford to loss the job.My parents have clearly told me that i do not need to worry in any case because they have saved enough money for me keeping in mind my illness where i can live without even doing job.
To say that there might be environmental influences on your mood is not to accuse you of anything. Do you notice that your mood is worse during times of stress? Do you notice that your mood changes with the seasons or duration of daylight? Do you notice that your mood fluctuates with varying levels of exercise etc etc.
It is not equal to accusing me but it means accusing my parents or family or environment or country.I have thought about these things a lot and conclusion is that my parents have been great to me.I tried to find the reasons to blame parents or family but i could not.And as far as my country is concerned,many surveys about measuring happiness have come out with similar conclusion that indians are the happiest people and most excited and optimistic about future.After seeing my country in past decade or so,i can not blame them because it is rapidly emerging as global superpower.
As far as my mood is concerned as i wrote in my earlier post too that i have dysthymia.It has not fluctuated significantly in 15 years so how it can fluctuate during the day or during bath or during excercise.It is the same gloomy for 24 hours never goes substantially up nor down.
Posted by linkadge on September 1, 2007, at 9:17:08
In reply to Re: To the people who don't believe in biological dep., posted by jhj on September 1, 2007, at 8:11:23
>There was a major study in real environment >starD done by NIMH.And after four phases 2/3 >patients reported remission(not >improvement).Majority is very subjective >things.There are countless studies showing >efficacy of all the drugs and advantage over >placebo.
I'd like to see a link to that. I remember reading some starD study but it lead to no 2/3 remitting.
The majority is the right word to use. There was some lady who essentially analyzed the results from all available published clinical trials on the newer antidepressants. Her findings were that when all clinical trials were considered, the antidepressants failed to outperform placebo.
>Well,i come from the country(India) where >psychiatry is discouraged and not >bolstered.India has taught alternative therapies >like yoga,meditation etc. to the world and they >are always preferred over medicines in India.Not >that i have not tried anything.I have tried CBT >too.But it is safe to say that >CBT,yoga,meditation are absolute piece of >rubbish that does not work.
For starters, its not fair to say, such and such is a "piece of rubbish that does not work". You don't know how well such treatments work for others, you only know how well they work for yourself. Just because a med, or a therapy doesn't work for you doesn't mean it doesn't help others.
Areobic exercise, such as running, is not the same as yoga. Running has been shown to increase PEA levels, serotonin levels, BDNF, GDNF, NGF, FGF-2, enhance hippocampal neurogenesis, regulate HPA axis function, alter serotonin/dopamine autoreceptor function, modulate gaba levels, increase nightime melatonin output, you name it.
Perhaps not everybody can run 30-45 min a day, but other exercises can help too.Exercise is *both* a environmental, and a biological treatment. This demonstrates the inseperability of the two. Environmental influences can have real biological impact.
No, exercise may not cure you, but it can help some reduce their medication, it can also help some get to remission.
Second of all, there are other alternatives that have antidepressant properties. SJW for instance, has outperformed standard antidepressants in many trials, some even for severe depression. There are other alternative treatments like SAMe, that have helped TRD in certain studies.Hallucinogens can produce remission from depression (albeit tempoarary) for some individuals, and they would be considered alternative. The antidepressant effect of other herbs has been established too.
Linkadge
Posted by jhj on September 1, 2007, at 9:40:51
In reply to Re: To the people who don't believe in biological dep., posted by linkadge on September 1, 2007, at 9:17:08
http://www.nimh.nih.gov/healthinformation/stard-qa-overall.cfm
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Questions and Answers about the NIMH Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study — All Medication LevelsNovember 20061. What were the goals of the STAR*D trial?
A. The overall goal of the STAR*D trial was to assess the effectiveness of depression treatments in patients diagnosed with major depressive disorder, in both primary and specialty care settings. It is the largest and longest study ever conducted to evaluate depression treatment. Read more about STAR*D.Each of the four levels of the study tested a different medication or medication combination. The primary goal of each level was to determine if the treatment used during that level could adequately treat participants' major depressive disorder (MDD). Those who did not become symptom-free could proceed to the next level of treatment.
The design of the STAR*D study reflects what is done in clinical practice because it allowed study participants to choose certain treatment strategies most acceptable to them and limited the randomization of each participant only to his/her range of acceptable treatment strategies. No prior studies have evaluated the different treatment strategies in broadly defined participant groups treated in diverse care settings.
2. Who participated in the study?
A. Over a seven-year period, the study enrolled 4,041 outpatients, ages 18-75 years, from 41 clinical sites around the country, which included both specialty care settings and primary medical care settings. Participants represented a broad range of ethnic and socioeconomic groups. All participants were diagnosed with MDD and were already seeking care at one of these sites. No media advertisements were used to recruit participants. Instead, they were referred to the trial by their doctors.So that results could be generalized to a broad group of real-world patients, most adults with MDD were eligible. People were not eligible for the study if they had not tolerated or did not get well with one or more of the treatments that were part of the first two STAR*D treatment steps, or if a STAR*D treatment could not be safely used because of another medical condition or because they were taking certain other medications. In addition, people with substance abuse disorders that required detoxification, anorexia or bulimia, or obsessive compulsive disorder were not eligible for the study because they required treatments that were not part of STAR*D.
Of the initial 4,041 participants, 1,165 were excluded because they either did not meet the study requirements of having "at least moderate" depression (based on a rating scale used in the study) or they chose not to participate. Thus, 2,876 "evaluable" people were included in level 1 results. Level 2 results include 1,439 people who did not become symptom-free in level 1 and chose to continue. Level 3 results include 377 people, and Level 4 results include 142 people.
3. What were the treatments used in the study?
A. In level 1, participants were given the antidepressant citalopram (Celexa) for 12 to 14 weeks. Those who became symptom-free during this time could move on to a 12-month follow-up period during which the citalopram was continued, and patients were monitored. Those who experienced intolerable side effects or did not become symptom-free during this level could go on to level 2.Citalopram is representative of the class of antidepressant medications known as selective serotonin reuptake inhibitors (SSRIs). It was chosen as the first treatment because it generally is not associated with troublesome withdrawal symptoms when it is stopped, is easy to administer (once a day), and has been shown to be safe for older adults and medically fragile patients. It does not appear to interact unfavorably with other medications that some participants may have been taking for other medical problems.
Level 2 was designed to help determine an appropriate next treatment step if the first step did not work. Thus, in level 2, participants had the option of switching to a different medication or adding on to their existing citalopram.
Those who joined the "switch" group were randomly assigned to either sertraline (Zoloft), bupropion-SR (Wellbutrin), or venlafaxine-XR (Effexor). These medications were chosen for comparison because they represent three different types of medications. Sertraline is an SSRI, the same class as the citalopram used in level 1. Bupropion belongs to another class of antidepressant medications that work on different neurotransmitters than SSRIs. Venlafaxine is a "dual-action" medication that works on two neurotransmitters at the same time.
Those who joined the "add-on" group were prescribed either the non-SSRI antidepressant bupropion-SR (Wellbutrin), or buspirone (BuSpar), which is not an antidepressant but enhances the action of an antidepressant medication. Participants could also switch to, or add on, cognitive psychotherapy.
As in level 1, those who became symptom-free with their level 2 treatment could continue with that treatment and entered the follow-up period. Those who did not become symptom-free, or who experienced intolerable side effects, could continue on to level 3.
In level 3, which like level 2 was designed to compare medications that are thought to work differently in the brain and produce different results, participants again had the option of either switching to a different medication or adding on to their existing medication. Those who chose to switch their medication were randomly assigned to either mirtazapine (Remeron) — a different type of antidepressant — or to nortriptyline (Aventyl or Pamelor) — a tricyclic antidepressant—for up to 14 weeks. Both work differently in the brain than the SSRIs and other medications used in levels 1 and 2.
In the level 3 add-on group, participants were randomly prescribed either lithium — a mood stabilizer commonly used to treat bipolar disorder — or triiodothyronine (T3) — a medication commonly used to treat thyroid conditions — to add to the medication they were already taking. These medications were chosen because they have been shown to boost the effectiveness of antidepressant medications.
In level 4, participants who had not become symptom-free in any of the previous levels (and therefore considered to have highly treatment-resistant depression) were taken off all other medications and randomly switched to one of two treatments — the monoamine oxidase inhibitor (MAOI) tranylcypromine (Parnate) or the combination of venlafaxine extended release (Effexor XR) with mirtazapine (Remeron). These treatments were chosen for comparison because previous research had suggested that they may be particularly effective in people who had not received sufficient benefit from other medications.
Chart of Treatment Choices Throughout STAR*D (PDF File, 1 page).
4. How were participant's doses decided and how was their progress measured?
A. To ensure that every participant had the best chance of recovery with each treatment strategy, a systematic approach called measurement-based care was used. This method requires routine, consistent measurement of symptoms and side effects at each treatment visit with easy-to-use measurement tools. It also involves the use of a treatment manual that describes when and how to modify medication doses and dose adjustments to best tailor them for individual participants so as to minimize side effects, maximize safety, and provide the best chance of therapeutic benefit. This enabled STAR*D practitioners to provide consistent, high-quality care.STAR*D employed easy-to-use rating tools of symptoms and side effects in a systematic and consistent way. These tools can readily be incorporated into real-world medical and psychiatric settings. Use of this measurement-based care may have caused greater than expected remission rates.
Patients were asked to self-rate their symptoms. The study demonstrated that most depressed patients can quickly and easily self-rate their symptoms and estimate their side effect burden in a very short time. Their doctors can rely on these self-rated tools for accurate and useful information to make informed judgments about treatment. The patients can also use these tools to help manage their illness at home in much the same way that hypertensive patients can measure their own blood pressure.
For more information about the treatment manuals and rating forms used in the STAR*D study, all of which are available for use at no cost, see the STAR*D website.
5. What were the results?
A. In most clinical trials of treatment for depression, the measure of success (outcome) is called "response" to treatment, which means that the person's symptoms have decreased to at least half of what they were at the start of the trial. In STAR*D, the outcome measure was a "remission" of depressive symptoms—becoming symptom-free. This outcome was selected because people who reach this goal generally function better socially and at work, and have a better chance of staying well than do people who only achieve a response but not a remission.In level 1, about one-third of the participants reached remission and about 10-15 percent more responded, but did not reach remission. Still, these are considered good results because study participants had high rates of chronic or recurrent depression and other psychiatric medical problems.
It took an average of six weeks of treatment for participants to improve enough to reach a response and nearly seven weeks of treatment for them to achieve a remission of depressive symptoms. In addition, participants visited their care providers an average of five to six times. Participants who achieved remission stayed on the treatment for an average of 12 weeks before going on to a 12-month follow-up period.
In the level 2 switch group, about 25 percent of participants became symptom-free. All three of the switch medications performed about the same and were equally safe and well-tolerated. In the add-on group, about one-third of participants became symptom-free. Those who added bupropion experienced less troublesome side effects and slightly more reduction of symptoms than those who added buspirone.
In levels 2 and 3 where participants were allowed to either add-on or switch medications, most participants found only one or the other treatment strategies acceptable. Because most participants did not agree to be randomly assigned to one or the other treatment strategy, the findings of the add-on and switch approaches cannot be compared. It is likely, however, that people being treated in the real world also tend to limit their treatment preferences to switching or adding on medications. In addition, the people in the switch and add-on groups were a little different. The group who chose and were assigned to a switch medication had more problematic side effects while taking the preceding medication (citalopram) than the group who chose and were assigned to an add-on medication.
Level 2 also included cognitive psychotherapy as a switch or add-on treatment. Results for the psychotherapy treatment are not yet available.
In the level 3 switch group, 12 to 20 percent of participants became symptom-free, and the two medications used fared about equally well, suggesting no clear advantage for either medication in terms of remission rates or side effects. In the add-on group, about 20 percent of participants became symptom-free, with little difference between the two treatments. However, the T3 treatment was associated with fewer troublesome side effects than lithium.
In level 4, seven to 10 percent of participants became symptom-free, with no statistically significant differences between the medications in terms of remission, response rates or side effect burden. However, those taking the venlafaxine-XR/mirtazapine combination experienced more of a reduction in depressive symptoms than those taking the tranylcypromine. Also, those who were treated with tranylcypromine were more likely to discontinue the treatment citing side effects as the reason. It is also possible that the dietary restrictions associated with taking an MAOI could have limited its acceptability as a treatment.
In conclusion, about half of participants in the STAR*D study became symptom-free after two treatment levels. Over the course of all four treatment levels, almost 70 percent of those who did not withdraw from the study became symptom-free. However, the rate at which participants withdrew from the trial was meaningful and rose with each level—21 percent withdrew after level 1, 30 percent withdrew after level 2 and 42 percent withdrew after level 3.
6. What lessons are learned from the results?
A. For the first time, doctors and people with depression now have extensive data on antidepressant treatments from a federally funded, large-scale, long-term study directly comparing treatment strategies.Results from level 2 indicate that if a first treatment with one SSRI fails, about one in four people who choose to switch to another medication will get better, regardless of whether the second medication is another SSRI or a medication of a different class. And if patients choose to add a new medication to the existing SSRI, about one in three people will get better. It appears to make some—but not much—difference if the second medication is an antidepressant from a different class(e.g. bupropion) or if it is a medication that is meant to enhance the SSRI (e.g. buspirone). Because the switch group and the add-on group cannot be directly compared to each other, it is not known whether patients are more likely to get better by switching medications or by adding another medication.
Results from level 3 apply to those who do not get better after two medication treatment steps. By switching to a different antidepressant medication, about one in seven people will get better. By adding a new medication to the existing one, about one in five people will get better. Level 3 results also tell us that adding T3 may have some advantages over adding lithium for patients who have tried two other treatments without success.
Finally, for patients with the most treatment-resistant depression, level 4 results suggest that tranylcypromine is limited in its tolerability and that up to 10 percent may benefit from the combination of venlafaxine-XR/mirtazapine.
An overall analysis of the STAR*D results indicates that patients with difficult-to-treat depression can get well after trying several treatment strategies, but the odds of beating the depression diminish with every additional treatment strategy needed. In addition, those who become symptom-free have a better chance of remaining well than those who experience only symptom improvement. And those who need to undergo several treatment steps before they become symptom-free are more likely to relapse during the follow-up period. Those who required more treatment levels tended to have more severe depressive symptoms and more co-existing psychiatric and general medical problems at the beginning of the study than those who became well after just one treatment level.
These results underscore both the need for a better understanding of how different people respond to different depression treatments, and the challenges in finding broadly effective, short- and long-term depression treatments. Future research may help identify which treatments work for which patients.
7. What do the STAR*D results mean to people with MDD and their doctors?
A. The results reiterate the need for high-quality care and attention to the individual needs of patients. Doctors should provide medication at optimal doses, be aware of and offer treatment choices, and maintain diligent monitoring of patients both during treatment and after they become symptom-free so as to avoid relapse.Like other medical illnesses, depression affects different people in different ways, but a wide range of effective treatments exist. People with depression should not give up if their initial treatment attempts do not result in full benefits. They should continue to work with their doctors to find the best treatment strategy.
In addition, patience is required. While some people may experience benefits in the first six weeks of a treatment strategy, full benefits may not be realized until 10 or 12 weeks have passed. During this time, doctors should work with their patients to adjust dosages so as to find an optimal level, and avoid stopping a treatment prematurely.
8. What more will be learned from the STAR*D study and what areas of future research will be influenced by STAR*D?
A. The STAR*D study results published to date provide important information about the effectiveness of current treatments in primary care and specialty settings in real world patients. Subsequent analyses of the STAR*D data include:results of cognitive therapy as a switch and add-on treatment;
factors affecting patient preferences in choosing next-step treatments when a first treatment is not successful;
comparison of the effectiveness of different treatments in preventing relapse; and
factors associated with relapse.
Also, blood samples that were voluntarily collected from more than 1,900 of the STAR*D participants will allow researchers to identify potential biological markers of disease course and treatment response.The results of STAR*D also underscore the need for more effective treatment strategies and more patient-tailored interventions for the treatment of major depression. Future research topics beyond STAR*D include:
developing methods to predict who will respond to which treatment and in what treatment sequence; and
evaluating combination medication strategies earlier in the course of treatment compared to single therapy strategies.
For More Information:
Questions and Answers about the NIMH Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study — Level 1 results, published in American Journal of Psychiatry, January 1, 2006.Questions and Answers about the NIMH Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study — Level 2 results, published in New England Journal of Medicine, March 23, 2006.
TopPosted: 11/08/2006
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This is the most comprehansive study of all.The study you are talking about such as about SAMe and herbal remedies are those studies which are published in numbers every day.That does not indicate anything.I would also like to clarify that i have tried at least 20 medicines but they have not given me any benefits at all.But,still i am not saying they are rubbish though they have not worked for me.The reason is i have seen many people recovering completely by using these medicines with my eyes.I have not seen anybody getting well through herbal remedies or meditation etc.I have found that use of herbal treatment for every diesease has incresed significantly in western countries in past few years.Before that time,very few even new about these remedies.While we have been trying these studies for at least three thousand years in uncontrolled environment so i can say that they are rubbish because we have experience of using these remedies for thousands of years and that too on human beings and not on rodents.
Posted by Brody on September 1, 2007, at 13:22:32
In reply to Re: To the people who don't believe in biological dep., posted by linkadge on September 1, 2007, at 9:17:08
"But it is safe to say that >CBT,yoga,meditation are absolute piece of >rubbish that does not work."
I have been following this thread with dubious curiosity, and at the level at which minds appear to be clearly made up, I don't know why I am jumping in here.BUT, my experience has been that after getting MDD stabilised with pharmological treament (and by stabilised I do not mean in remission, I mean getting to the point of being relatively functional), I recently entered CBT and I find that I am finally able to successfully challenge many of my negative thinking patterns. The combination of treatments has been successful for me in a way that 30 years of AD treatment alone never achieved.
While in a highly depressed state, I would not have benefited from CBT because I did not have the energy or will to give it the effort it requries. At the gentle suggestions of my p-doc, my family, and my friends, I still refused to give it a try. Finally, I was well enough to be willing.
Did you go into CBT with the belief that it had the potential to produce benefits? I could understand that if the patient doesn't believe in the process from the outset, it would be a non-productive endeavor and a failure as a treatment option.
Doesn't work for you? Very sorry to hear that. Rubbish? Decidedly not.
Posted by linkadge on September 1, 2007, at 13:26:48
In reply to Re: To the people who don't believe in biological dep., posted by jhj on September 1, 2007, at 9:40:51
Without a placebo arm, the results are kind of meaningless.
Linkadge
Posted by Phillipa on September 1, 2007, at 20:18:33
In reply to Re: To the people who don't believe in biological dep., posted by linkadge on September 1, 2007, at 9:17:08
I'm a different person after excercise and when younger was a runner. Nothing can top the runners's high. Took on .125mg of xanax then. Now since my discs are bad I make a point of riding my bike 7.5miles daily no shifts or gears up steep hills. Always feel better when done. Phillipa
Posted by jhj on September 2, 2007, at 0:59:01
In reply to Re: To the people who don't believe in biological dep., posted by linkadge on September 1, 2007, at 13:26:48
Without a placebo arm, the results are kind of meaningless
This is a huge statement.there was a "remission" of depression for 70% of patients and not only improvement.If it happens by placebo effect well,i would certainly like to have this placebo.This study was conducted by National institute of mental health and not by any of those who everyday publish placebo controlled trials in numbers. Bt the way,when you read these "placebo controlled" studies on none other then "rodents" you also read the name of financer.Most of those studies are funded by NIMH.I think before you read about sequential treatment alternatives to relieve depression study,it would have been batter if you had found out something about NIMH and its reputation.By the way,i again want to say something about herbal remedies that you people are finding increasingly significant for all the diseases.I would like to recount an incidence which happened to one of my colleuge.He entered a chat room where common cold was being discussed and somebody from europe told him that neem is very good for common cold and to be fair to that person he gave links to three-four studies too.My colleuge read the studies and then started laughing.When i enquired about the reason,he showed me those studies which were similar.Those were placebo controlled trials conducted on around 50 people and the conclusion was that "This treatment looks promising and larger clinical trials are required to raplicate the findings of this study".In India,our monks and our grand mothers have been using it for thousands of years and my grandmom can tell these "scientists" by just seeing the patient's symptoms whether neem would work or not with almost 100% certainty.The only problem with our grandmothers is that they do not know anything about "peer reviewed articles" in reputed journals like "Lancet" or Patent laws.They also do not know how to use internet nor they know english so one can not find links to their studies.When western doctors preach about the virtues of herbal therapies,it looks quite funny.It is like somebody who has just learned how to hold tannis raquet in hand teaching somebody who has won multiple grandslams.Sorry if i am sounding irritating.
Posted by jhj on September 2, 2007, at 1:10:26
In reply to Re: To the people who don't believe in biological dep., posted by Brody on September 1, 2007, at 13:22:32
Unfortunately to say but,i went into CBT exactly thinking that it would work for me.After 12 Sessions my therapist told me that,i am unlikely to improve because my symptoms are very deeply rooted and there is strong comorbidity with GAD,social phobia etc..When you have all those problems simultaneously from childhood,you can not challange irrational thoughts because you are already comprehensively beaten by these thoughts.
Posted by FredPotter on September 2, 2007, at 15:42:39
In reply to Re: To the people who don't believe in biological dep., posted by linkadge on September 1, 2007, at 13:26:48
Exactly - what waste of time, money and effort. It's also not clear what samples or populations the percentages refer to
Posted by FredPotter on September 2, 2007, at 15:48:55
In reply to Re: To the people who don't believe in biological dep., posted by jhj on September 2, 2007, at 0:59:01
I don't slavishly believe an insitute's work because of its reputation. We must all be peer-reviewers. We know a lot on this board. Incidentally I know of a peer-reviewed (of course) paper in the Lancet on the 4S Scandinavian Statin study. It contains a serious mistake or it is fraudulent. Either way it negates the conclusion of the trial
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