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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 11 of 11. This is the beginning of the thread.
Posted by dcruik518 on August 3, 2008, at 18:38:54
The latest issue of the Harvard Mental Health Letter lays out an interesting and successful protocol for finding the right depression medication(s). It's called STAR-D and it stands for Sequenced Treatment Alternatives to Relieve Depression. The study found good results. Each trial was given 8wks to work, as they found one of the most common reasons for treatment failure was early termination.
Level 1: Celexa 33% remission rate
Level 2. Switch to Zoloft, Effexor, or augment Celexa with Wellbutrin or Buspar.
57% remission rateLevel 3. Stop current meds. Switch to Remeron or Nortriptyline. Augment current therapy with lithium or T3 thyroid hormone (Cytomel).
63% remission rate.(Study also found new generation antipsychotics are also effective augmentation agents: Risperdal, Zyprexa, Geodon, and Seqoquel act synergistically with AD's in some patients.) For some reason Abilify not mentioned.
Level 4. Stop current therapy and switch to Parnate, Nardil, or Remeron + Effexor.
67% Remission rate.
This is the largest study conducted of it's kind, enrolling 3671 patients at 41 sites nationwide.
Other agents: investigators are also researching testosterone, estrogen, SAMe, Omega 3 fatty acids, and variety of anticonvulsants.Questions? let me know, there's more to article.
~DRC
Posted by dcruik518 on August 3, 2008, at 18:50:35
In reply to Harvard's (STAR-D*) protocol to treat depression, posted by dcruik518 on August 3, 2008, at 18:38:54
Posted by raisinb on August 3, 2008, at 19:07:05
In reply to Re: (STAR-D*) helpful link for more info., posted by dcruik518 on August 3, 2008, at 18:50:35
Interesting! Suggests (as we already know...) this stuff is more complicated than we think. I guess they are hypothesizing that the early meds enable the later ones to work?
Posted by linkadge on August 3, 2008, at 19:54:08
In reply to Re: (STAR-D*) helpful link for more info. » dcruik518, posted by raisinb on August 3, 2008, at 19:07:05
I'd like them to follow remission rates and determine relapse rates. Also, a placebo arm would be nice to sort out real from placebo response.
Linkadge
Posted by Larry Hoover on August 3, 2008, at 21:10:07
In reply to Re: (STAR-D*) helpful link for more info., posted by linkadge on August 3, 2008, at 19:54:08
> I'd like them to follow remission rates and determine relapse rates.
This paper fully discusses those two issues: http://ajp.psychiatryonline.org/cgi/content/full/163/11/1905
I think an interesting finding is that full remission occurred about 50% of the time between treatment weeks 6 and 12, calling into question the findings of clinical trials of short duration. Very few even monitor for 12 weeks, and may thus miss successful treatment outcomes.
> Also, a placebo arm would be nice to sort out real from placebo response.
>We've already discussed at some length why placebo could not have been part of this trial. STAR*D was a naturalistic study, and no practitioners employ placebo in their medical practise.
Lar
Posted by Larry Hoover on August 3, 2008, at 21:13:42
In reply to Re: (STAR-D*) helpful link for more info. » dcruik518, posted by raisinb on August 3, 2008, at 19:07:05
> Interesting! Suggests (as we already know...) this stuff is more complicated than we think. I guess they are hypothesizing that the early meds enable the later ones to work?
No, that's not what the trial demonstrates. It shows a sequence of treatment options that might be instituted if the earlier treatments fail. There is no evidence that an earlier failed treatment predisposes to later success. Instead, subsequent treatment should be selected based on differing mechanism of action, in hopes that the novel approach will work where another had not.
Lar
Posted by Larry Hoover on August 3, 2008, at 21:15:27
In reply to Harvard's (STAR-D*) protocol to treat depression, posted by dcruik518 on August 3, 2008, at 18:38:54
If you search on this site, you'll see that we've had some lengthy discussion on this trial. Many different views have been aired.
Lar
Posted by Nadezda on August 3, 2008, at 22:59:58
In reply to Re: Harvard's (STAR-D*) protocol to treat depression » dcruik518, posted by Larry Hoover on August 3, 2008, at 21:15:27
Have there been any follow-up results since the initial results? The study was continuing at the time of the prior thread.
Some of the stages mentioned here seem new and not part of the earlier report.
Also-- there's almost no one left after stage 3 and even fewer after stage 4-- based on 3600 people-- so I wonder if these statistics are accurate, actually.
Nadezda
Posted by Phillipa on August 4, 2008, at 0:25:37
In reply to Re: Harvard's (STAR-D*) protocol to treat depressi, posted by Nadezda on August 3, 2008, at 22:59:58
So it's the same Star D study? Phillipa
Posted by Larry Hoover on August 4, 2008, at 7:27:12
In reply to Re: Harvard's (STAR-D*) protocol to treat depressi, posted by Nadezda on August 3, 2008, at 22:59:58
> Have there been any follow-up results since the initial results? The study was continuing at the time of the prior thread.
There are over 100 papers that come up on Pubmed using STAR*D as keyword for searching.
> Some of the stages mentioned here seem new and not part of the earlier report.
There are many follow-up reports, looking at narrow aspects of the findings.
> Also-- there's almost no one left after stage 3 and even fewer after stage 4-- based on 3600 people-- so I wonder if these statistics are accurate, actually.
>
> NadezdaThe stats are the stats. If the results are significant, then they have meaning. Extrapolation from small samples is less robust, yes.
Lar
Posted by linkadge on August 4, 2008, at 11:53:49
In reply to Re: (STAR-D*) helpful link for more info. » linkadge, posted by Larry Hoover on August 3, 2008, at 21:10:07
>We've already discussed at some length why >placebo could not have been part of this trial. >STAR*D was a naturalistic study, and no >practitioners employ placebo in their medical >practise.
Or do they? :)
Linkadge
This is the end of the thread.
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