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Treatment-Resistant Switch Or Augment? Choices That Depression Improve Response Rates

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Treatment-Resistant Switch Or Augment? Choices That Depression Improve Response Rates Current p SYCHIATRY Treatment-resistant Switch or augment? Choices that depression improve response rates hen depression fails to respond to ini- When initial antidepressant tial therapy—as it commonly does— therapy fails, an algorithmic we have many options but little evi- Wdence to guide our choices. We often wonder: approach to medication is more • Is this patient’s depression treatment- resistant? effective than treatment-as-usual. • Would switching medications or augment- ing the initial drug be more likely to achieve an adequate response? • How effective is psychotherapy compared with medication for treatment-resistant A. John Rush, MD depression? Professor and vice-chairman for research This article offers insights into each question, Betty Jo Hay Distinguished Chair in Mental Health based on available trial data, algorithmic Rosewood Corporation Chair in Biomedical Science approaches to major depressive disorder, and Department of Psychiatry University of Texas Southwestern Medical Center clinical experience. Included is a preview of an Dallas ongoing multicenter, treatment-resistant depres- sion study that mimics clinical practice and a look at vagus nerve stimulation (VNS)—a novel somatic therapy being considered by the FDA. MEASURING TREATMENT RESPONSE Sustained symptom remission—with normaliza- tion of function—is the aim of treating major depressive disorder. Outcomes are categorized as: • remission (virtual absence of depressive symptoms) © John Ritter / Images.com, Inc. continued VOL. 3, NO. 3 / MARCH 2004 11 Treatment-resistant depression Box • response with residual symptoms (>50% re- Major depressive disorder: duction in baseline symptom severity that does Common and disabling not qualify for remission) • partial response (>25% but <50% decrease Major depressive disorder (MDD) is typically in baseline symptom severity) recurrent or chronic and characterized by • nonresponse (<25% reduction in baseline marked disability and a life expectancy symptoms). shortened by suicide and increased mortality In 8-week acute-phase trials, 7% to 15% of from associated medical conditions. Lifetime patients do not tolerate the initial medication, 6 prevalence is 16.2%. 25% show no response, 15% show partial MDD is twice as likely to affect women as response, 10% to 20% exhibit response with resid- men and is common among adolescents, ual symptoms, and 30% to 40% achieve remis- young adults, and persons with concurrent medical conditions. sion. Complicated depressions that may not respond as well include those concurrent with Major depression’s course is characterized by: Axis I conditions—such as panic disorder or sub- • recurrent episodes (approximately stance abuse—or Axis II or III conditions.1 every 5 years) Time-limited psychotherapies targeted at • or a persistent level of waxing and depressive symptoms (such as cognitive, interper- waning depressive symptoms (in 20% to 35% of cases). sonal, and behavioral therapies) also typically achieve a 50% response rate in uncomplicated Dysthymic disorder often heralds major depression. Within 1 year, 5% to 20% depression that is not treatment-resistant. of persons with dysthymic disorder develop Recommendation. When treating depression, major depression.7 assess response at least every 4 weeks (preferably at each visit), using a self-report or clinician rating such as: Disability associated with major depression often exceeds that of other general medical • Quick Inventory of Depressive Symp- 2 conditions. Depression is the fourth most tomatology (see Related resources) disabling condition worldwide and is projected • Beck Depression Inventory3,4 to rank number two by 2020 because of its • Patient Health Questionnaire.5 chronic and recurrent nature, high prevalence, 8 and life-shortening effects. DEFINING TREATMENT RESISTANCE Consequences of unremitting A patient may not achieve remission for a variety depression include: of reasons, including poor adherence, inadequate • poor day-to-day function (work, family) medication trial or dosing, occult substance • increased likelihood of recurrence abuse, undiagnosed medical conditions (Box),6-8 • psychiatric or medical complications, concurrent Axis I or II disorders, or treatment including substance abuse resistance. • high use of mental health and general The general consensus is to consider depres- medical resources sion “treatment-resistant” when at least two ade- • worsened prognosis of medical quately delivered treatments do not achieve at conditions least a response. A stricter definition—failure to • high family burden. achieve sustained remission with two or more treatments—has also been suggested. Several schemes have proposed treatment 12 Current VOL. 3, NO. 3 / MARCH 2004 p SYCHIATRY Current p SYCHIATRY resistance levels, such as the five Table stages identified in the Ta b l e . Simple system for staging antidepressant resistance Recent studies9,10 suggest that increasing treatment resistance is Stage Definition associated with decreasing response or remission rates. I Failure of at least one adequate trial of one major antidepressant class Therefore, when a patient’s treatment resistance is high, two II Stage I resistance plus failure of an adequate trial of an antidepressant in a distinctly different class from appropriate strategies are to: that used in Stage I • persist with and use max- imally tolerated dosages of the III Stage II resistance plus failure of an adequate trial of a tricyclic antidepressant treatment you select • aim for response because IV Stage III resistance plus failure of an adequate trial of high resistance lowers the likeli- a monoamine oxidase inhibitor hood of remission. V Stage IV resistance plus failure of a course of bilateral Predicting response. A major electroconvulsive therapy Source: Reprinted with permission from Thase ME, Rush AJ. When at first you don’t succeed: clinical issue is determining sequential strategies for antidepressant nonresponders. J Clin Psychiatry 1997;58(suppl 13):24. whether remission will occur during an acute treatment trial. It is important to not declare treatment resistance weeks, continue treating another 4 to 6 weeks, unless there has been: increasing the dosage as tolerated. • adequate exposure (dosing and duration) to the treatment TREATMENT OPTIONS • and adequate adherence. When initial antidepressant treat- Patients often have apparent Continue a treatment ment fails to achieve an adequate but not actual resistance, meaning at least 6 weeks response—as it does in more than one- that the agent was not used long before you decide half of major depression cases—the enough (at least 6 weeks) or at that it will not next step is to add a second agent or high enough doses. Remission achieve a response switch to another agent. typically follows response by sever- Available evidence14 relies almost al weeks or even 1 to 2 months for exclusively on open, uncontrolled trials, more-chronic depressions.11 Thus, treatment tri- which do not provide definitive als should continue at least 12 weeks to determine answers. Even so, these trials indicate that nonre- whether remission will occur. sponse (or nonremission) with one agent does not On the other hand, not obtaining at least a sig- predict nonresponse/nonremission with another. nal of minimal benefit (at least a 20% reduction in Switching strategies. When a selective serotonin baseline symptom severity) in 4 to 6 weeks often reuptake inhibitor (SSRI) is the first treatment, portends a low likelihood of response in the long several open trials reveal an approximately 50% run.12,13 Thus, continue a treatment at least 6 weeks response rate to a second SSRI. However, open- before you decide that it will not achieve a response. trial evidence and retrospective chart review Recommendation. Measure symptoms at key deci- reports also indicate that switching out of class sion points. If modest improvement (such as 20% (such as from an SSRI to bupropion) is also reduction in baseline symptoms) is found at 4 to 6 approximately 50% effective.15 VOL. 3, NO. 3 / MARCH 2004 13 Treatment-resistant depression Some post hoc analyses of acute 8-week trials Psychotherapy may also play a key role in aug- indicate that the dual-action agent venlafaxine at menting medication’s effects. Keller et al23 found higher dosages (up to 225 mg/d of venlafaxine XR) in chronically depressed outpatients that 12 is associated with higher remission rates than the weeks of nefazodone, up to 600 mg/d, plus cog- more-selective SSRIs.16,17 On the other hand, nitive behavioral analytic system psychotherapy unpublished data indicate that escitalopram, 10 (CBASP) produced higher response and remis- mg/d, and venlafaxine XR, up to 150 mg/d, did not sion rates compared with either treatment alone. differ in efficacy among outpatients treated by pri- A subsequent report24 found that 50% of nefa- mary care physicians.18 zodone and CBASP monotherapy nonrespon- On the other hand, sertraline and imipramine ders did respond when switched to the alternate (a dual-action agent) were equally effective in a treatment. 12-week acute-phase trial.19 Furthermore, Thus, CBASP may be useful at least in response and remission rates were similar when chronic depression to augment medication or as a nonresponders in each group switched to “switch” to monotherapy if medication alone fails. the other antidepressant.20 This suggests that the Interestingly, Nemeroff et dual-action agent (imipramine) al25 found CBASP more effec- was not more effective than the tive than nefazodone
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