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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 18 of 18. This is the beginning of the thread.
Posted by Bob on May 3, 2011, at 22:09:17
Dual Medications For Depression Increases Costs, Side Effects With No Benefit To Patients
02 May 2011
Taking two medications for depression does not hasten recovery from the condition that affects 19 million Americans each year, researchers at UT Southwestern Medical Center have found in a national study.
"Clinicians should not rush to prescribe combinations of antidepressant medications as first-line treatment for patients with major depressive disorder," said Dr. Madhukar H. Trivedi, professor of psychiatry and chief of the division of mood disorders at UT Southwestern and principal investigator of the study, which is available online today and is scheduled for publication in an upcoming issue of the American Journal of Psychiatry.
"The clinical implications are very clear - the extra cost and burden of two medications is not worthwhile as a first treatment step," he said.
In the Combining Medication to Enhance Depression Outcomes, or CO-MED, study, researchers at 15 sites across the country studied 665 patients ages 18 to 75 with major depressive disorder. Three treatment groups were formed and prescribed antidepressant medications already approved by the Food and Drug Administration. One group received escitalopram (a selective serotonin reuptake inhibitor, or SSRI) and a placebo; the second group received the same SSRI paired with bupropion (a non-tricyclic antidepressant); and a third group took different antidepressants: venlafaxine (a tetracyclic antidepressant) and mirtazapine (a serotonin norepinephrine reuptake inhibitor). The study was conducted from March 2008 through February 2009.
After 12 weeks of treatment, remission and response rates were similar across the three groups: 39 percent, 39 percent and 38 percent, respectively, for remission, and about 52 percent in all three groups for response. After seven months of treatment, remission and response rates across the three groups remained similar, but side effects were more frequent in the third group.
Only about 33 percent of depressed patients go into remission in the first 12 weeks of treatment with antidepressant medication, as Dr. Trivedi and colleagues previously reported from the Sequenced Treatment Alternatives to Relieve Depression, or STAR*D, study. STAR*D was the largest study ever undertaken on the treatment of major depressive disorder and is considered a benchmark in the field of depression research. That six-year, $33 million study initially included more than 4,000 patients from sites across the country. Dr. Trivedi was a co-principal investigator of STAR*D.
The next step, Dr. Trivedi said, is to study biological markers of depression to see if researchers can predict response to antidepressant medication and, thus, improve overall outcomes.
Other UT Southwestern researchers involved in the study were Drs. Benji Kurian and David Morris, assistant professors of psychiatry; Dr. Diane Warden, associate professor of psychiatry; and Dr. Mustafa Husain, professor of psychiatry, internal medicine, and neurology and neurotherapeutics. Former UT Southwestern professor Dr. A. John Rush, now with the Duke-NUS Graduate Medical School in Singapore, and researchers from the University of Pittsburgh; Massachusetts General Hospital; Columbia University College of Physicians and Surgeons; the University of California, Los Angeles; Vanderbilt University; Harbor-UCLA Medical Center; Virginia Commonwealth University; and Columbia University Medical Center also contributed.
The study was funded by the National Institute of Mental Health. Forest Pharmaceuticals, GlaxoSmithKline, Organon and Wyeth Pharmaceuticals provided the medications.
Source:
UT Southwestern Medical Center
Posted by SLS on May 3, 2011, at 23:21:49
In reply to This study seems to cast a shadow on med combos..., posted by Bob on May 3, 2011, at 22:09:17
I am curious as to what are your current beliefs regarding the use of multiple antidepressants. Has this article convinced you of anything?
- Scott
> Dual Medications For Depression Increases Costs, Side Effects With No Benefit To Patients
>
> 02 May 2011
>
> Taking two medications for depression does not hasten recovery from the condition that affects 19 million Americans each year, researchers at UT Southwestern Medical Center have found in a national study.
>
> "Clinicians should not rush to prescribe combinations of antidepressant medications as first-line treatment for patients with major depressive disorder," said Dr. Madhukar H. Trivedi, professor of psychiatry and chief of the division of mood disorders at UT Southwestern and principal investigator of the study, which is available online today and is scheduled for publication in an upcoming issue of the American Journal of Psychiatry.
>
> "The clinical implications are very clear - the extra cost and burden of two medications is not worthwhile as a first treatment step," he said.
>
> In the Combining Medication to Enhance Depression Outcomes, or CO-MED, study, researchers at 15 sites across the country studied 665 patients ages 18 to 75 with major depressive disorder. Three treatment groups were formed and prescribed antidepressant medications already approved by the Food and Drug Administration. One group received escitalopram (a selective serotonin reuptake inhibitor, or SSRI) and a placebo; the second group received the same SSRI paired with bupropion (a non-tricyclic antidepressant); and a third group took different antidepressants: venlafaxine (a tetracyclic antidepressant) and mirtazapine (a serotonin norepinephrine reuptake inhibitor). The study was conducted from March 2008 through February 2009.
>
> After 12 weeks of treatment, remission and response rates were similar across the three groups: 39 percent, 39 percent and 38 percent, respectively, for remission, and about 52 percent in all three groups for response. After seven months of treatment, remission and response rates across the three groups remained similar, but side effects were more frequent in the third group.
>
> Only about 33 percent of depressed patients go into remission in the first 12 weeks of treatment with antidepressant medication, as Dr. Trivedi and colleagues previously reported from the Sequenced Treatment Alternatives to Relieve Depression, or STAR*D, study. STAR*D was the largest study ever undertaken on the treatment of major depressive disorder and is considered a benchmark in the field of depression research. That six-year, $33 million study initially included more than 4,000 patients from sites across the country. Dr. Trivedi was a co-principal investigator of STAR*D.
>
> The next step, Dr. Trivedi said, is to study biological markers of depression to see if researchers can predict response to antidepressant medication and, thus, improve overall outcomes.
>
> Other UT Southwestern researchers involved in the study were Drs. Benji Kurian and David Morris, assistant professors of psychiatry; Dr. Diane Warden, associate professor of psychiatry; and Dr. Mustafa Husain, professor of psychiatry, internal medicine, and neurology and neurotherapeutics. Former UT Southwestern professor Dr. A. John Rush, now with the Duke-NUS Graduate Medical School in Singapore, and researchers from the University of Pittsburgh; Massachusetts General Hospital; Columbia University College of Physicians and Surgeons; the University of California, Los Angeles; Vanderbilt University; Harbor-UCLA Medical Center; Virginia Commonwealth University; and Columbia University Medical Center also contributed.
>
> The study was funded by the National Institute of Mental Health. Forest Pharmaceuticals, GlaxoSmithKline, Organon and Wyeth Pharmaceuticals provided the medications.
>
> Source:
> UT Southwestern Medical Center
Posted by Bob on May 3, 2011, at 23:49:45
In reply to Re: This study seems to cast a shadow on med combos... » Bob, posted by SLS on May 3, 2011, at 23:21:49
> I am curious as to what are your current beliefs regarding the use of multiple antidepressants. Has this article convinced you of anything?
>
>
> - Scott
>
>
Scott -As you might expect, this article has not convinced me of much. I guess I wouldn't disagree with not using more than one med as a first line treatment, but after that I'm not so sure. I think that in recent years I've become somewhat disenchanted with what a scientific study - no matter how well designed and executed - can really tell us. Each outcome is such a small part of an enormously complex problem. Having said that, I cannot resist constantly reading about these studies and hoping for some kernel of magical truth.
Bob
Posted by SLS on May 4, 2011, at 6:53:16
In reply to Re: This study seems to cast a shadow on med combos... » SLS, posted by Bob on May 3, 2011, at 23:49:45
Hi Bob.
> > I am curious as to what are your current beliefs regarding the use of multiple antidepressants. Has this article convinced you of anything?
> As you might expect, this article has not convinced me of much. I guess I wouldn't disagree with not using more than one med as a first line treatment, but after that I'm not so sure.You are exactly right. This is precisely the conclusion of the authors as can be found in the text of the article. I guess they aren't revealing anything new that is not already in common practice.
> I think that in recent years I've become somewhat disenchanted with what a scientific study - no matter how well designed and executed - can really tell us. Each outcome is such a small part of an enormously complex problem. Having said that, I cannot resist constantly reading about these studies and hoping for some kernel of magical truth.
I would have to agree with you.
One day, imaging and gene activity assay technologies will facilitate more precision in choosing treatments. One consequence of this will be utilizing combination treatments as a first-line strategy.
- Scott
Posted by floatingbridge on May 4, 2011, at 10:37:11
In reply to Re: This study seems to cast a shadow on med combos... » Bob, posted by SLS on May 4, 2011, at 6:53:16
That imaging technologies in place were available to those other than a minority of test subjects :(
Posted by Phillipa on May 4, 2011, at 10:55:46
In reply to Re: This study seems to cast a shadow on med combos... » SLS, posted by floatingbridge on May 4, 2011, at 10:37:11
I feel it's interesting that the funding seems to be both by NIMH and the dug companies. Phillipa
Posted by SLS on May 4, 2011, at 10:57:35
In reply to Re: This study seems to cast a shadow on med combos..., posted by Phillipa on May 4, 2011, at 10:55:46
> I feel it's interesting that the funding seems to be both by NIMH and the dug companies. Phillipa
How so?
- Scott
Posted by Terry8 on May 4, 2011, at 12:25:22
In reply to Re: This study seems to cast a shadow on med combos..., posted by Phillipa on May 4, 2011, at 10:55:46
> I feel it's interesting that the funding seems to be both by NIMH and the dug companies. Phillipa
The funding was by NIMH. The drug companies simply provided the drugs. And even if they had also provided funding, it's not like the results being reported benefit the drug companies.
From what I understand, their results only address combos versus monotherapy as a first-line treatment. I wasn't aware that it was even that common to prescribe more than one AD as a first-line treatment. I'll be more intrigued when I see results that address monotherapy versus combos for treatment resistant cases, which is when you see combos being used more often.
Posted by europerep on May 4, 2011, at 17:31:05
In reply to This study seems to cast a shadow on med combos..., posted by Bob on May 3, 2011, at 22:09:17
> Dual Medications For Depression Increases Costs, Side Effects With No Benefit To Patients
Hmm, I remember a study published in Biological Psychiatry not too long ago that said exactly the opposite. I think it was bupropion + mirtazapine that was used, and remission rates were almost double compared to either of those two alone. If I were a psychiatrist, I wouldn't start right out on a patient with two drugs I think, but I still hear people occasionally say that polypharmacy is a no-no in depression treatment, and I certainly disagree with that.
Posted by Phillipa on May 4, 2011, at 20:18:57
In reply to Re: This study seems to cast a shadow on med combos... » Phillipa, posted by SLS on May 4, 2011, at 10:57:35
I feel Terry 8 cleared this up for me. Phillipa
Posted by SLS on May 4, 2011, at 20:33:54
In reply to Re: This study seems to cast a shadow on med combos... » SLS, posted by Phillipa on May 4, 2011, at 20:18:57
> I feel Terry 8 cleared this up for me. Phillipa
I don't understand. What needed to be cleared up?
> > > I feel it's interesting that the funding seems to be both by NIMH and the dug companies
I am still curious what you were describing in your first post. Why did you feel that this was interesting?
- Scott
Posted by hyperfocus on May 4, 2011, at 21:35:01
In reply to This study seems to cast a shadow on med combos..., posted by Bob on May 3, 2011, at 22:09:17
I cannot really understand these studies because:
a)They're assuming that 'major depression' is a cleary defined disorder with very specific biological markers for diagnosis and treatment. Mental illness isn't like heart disease or high blood pressure or diabetes. It seems to me you could pick 100 people diagnosed with MDD and find that you needed 100 indivdual treatment plans to bring all of them to remission. You can't just lump everybody into one group. It just seems like really bad science.
b)Different ADs are not uniform in their theraputic response. ADs are not like other drugs like statins or beta-blockers. A person can respond to one AD and not to another, in the same class or otherwise. There's no explanation why somebody doesn't respond to Effexor but does to Cymbalta, or Prozac vs. Paxil. Or why they can have zero response to 3 drugs given individually but do respond to some combination of the three, but only at a specific dosage. Again it just seems like bad science.
One of these days somebody is going to do a metastudy which shows that for any set of conclusions any study on mental illness reaches, you can present another study that completely contradicts those conclusions. I know you need nice labels for your data in order to do empirical investigations, but if your labels don't match the reality of the disease then you're just going to end up in silliness.
Posted by Bob on May 4, 2011, at 21:57:57
In reply to Re: This study seems to cast a shadow on med combos..., posted by hyperfocus on May 4, 2011, at 21:35:01
>
> One of these days somebody is going to do a metastudy which shows that for any set of conclusions any study on mental illness reaches, you can present another study that completely contradicts those conclusions.
I think all of this is a done deal... except for the actual metastudy. We can already find contradictory studies quite readily.
Posted by ron1953 on May 5, 2011, at 10:06:41
In reply to This study seems to cast a shadow on med combos..., posted by Bob on May 3, 2011, at 22:09:17
The human body is complex beyond all human understanding, yet the so-called experts would have us believe that they actually know what they're talking about. Couple that with Big Pharma and you have our current situation regarding psychiatric medications, which have effectiveness rates WAY lower than advertised, and in many cases no better than placebo. As one who was once (but no longer) on the medication merry-go-round I'm quite familiar with drug combo trial-and-error, which didn't make a darn bit of difference.
I've come to believe a few things:
1) Physicians don't know nearly as much as their patients think they do.
2) Psychiatrists are often like drug dealers, profiting on patients' desperation.
3) Drug companies manipulate studies, offer doctors incentives, and more, purely for profit-seeking.
4) Struggling patients will continue trying new drugs forever, even when their experience has been that the effectiveness is nil or short-lived.
5) The placebo effect is not to be underestimated.I'm glad when studies such as the one cited are published, shedding doubt on dubious pratices and beliefs. But it shouldn't require a study to listen to common sense.
None of this is to say that I feel great, and have mastered my psychic discomfort. I simply have come to the conclusion that psych medications only make it worse for me, and others it seems, too.
Posted by ron1953 on May 5, 2011, at 10:13:53
In reply to Re: This study seems to cast a shadow on med combos..., posted by ron1953 on May 5, 2011, at 10:06:41
Almost forgot. For additional perspective, I suggest reading "Commonsense Rebellion: Taking Back Your Life from Drugs, Shrinks, Corporations, and a World Gone Crazy"
Posted by mtdewcmu on May 5, 2011, at 14:37:13
In reply to Re: This study seems to cast a shadow on med combos..., posted by Phillipa on May 4, 2011, at 10:55:46
> I feel it's interesting that the funding seems to be both by NIMH and the dug companies. Phillipa
I wish NIMH would do more studies like this, with drugs that are off-patent, to learn how to better use them. When you rely on the drug companies to do all the studies, you only get studies of expensive new drugs, and you only get studies that are designed to show what the manufacturer wants to show. Plus, the companies won't do studies that involve other companies' drugs, except in rare cases, or where they are hoping to prove superiority.
Posted by Chris O on May 8, 2011, at 2:00:58
In reply to This study seems to cast a shadow on med combos..., posted by Bob on May 3, 2011, at 22:09:17
"Studies" like this really upset me. I have to assume this one was done for some compassionate, empathic reason (perhaps to reduce drug costs for patients). However, as those of us know who have to take multiple medications, we are only doing it because it is ... the only thing that does work! Come on, now. Does anyone really even go down the path of taking multiple meds unless they are desperate? Does anyone continue to take multiple meds unless it is benefiting him/her in some way? And, even if the benefit is only perceptual (placebo-esque), if it is making us better functioning, well, then, that is all that matters.
Posted by SLS on May 8, 2011, at 6:40:03
In reply to Re: This study seems to cast a shadow on med combos..., posted by Chris O on May 8, 2011, at 2:00:58
> "Studies" like this really upset me.
Me, too, especially when people make treatment decisions based upon them. There is actually an ongoing project to discover under what circumstances it makes sense to make a drug combination the first-line treatment.
The following study was conducted by some very well respected names in the field. They may not have chosen drug combinations that are more globally effective. Perhaps their choice of subjects unintentionally excluded cases that would ultimately demonatrate treatment resistance.
http://www.ncbi.nlm.nih.gov/pubmed/21536692
I must discount this study simply because my observations in real life demonstrates the superiority of combination treatments anecdotally. This is not a scientific approach, I know. However, I cannot discount what my own eyes tell me. I feel that administering a combination of medications as a first line treatment has not been studied often enough to rely on the results of one study.
http://www.ncbi.nlm.nih.gov/pubmed/19573474
- Scott
This is the end of the thread.
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