Treating to Remission for Depression

"This is the outcome that should be targeted," Michael Thase MD of the University of Pittsburgh told a Sunday morning symposium, which meant "no symptoms" and a "return to functional self," corresponding to a Hamilton-17 Depression score of 7 or lower. Dr Thase cited a UK study that showed a 70 percent relapse over 15 months for those who merely responded on antidepressants (ie a partial improvement in symptoms). In contrast, there was only a 20 percent relapse among the remitters on meds, a difference of 3.5 times.

The response/remission figures played out with patients in talking therapy, according to a University of Pittsburgh study. There, the relapse rate for remitted patients was 10 percent over one year vs a 50 percent relapse rate for the responders, a five times difference.

Over 10 years, 30 percent of remitters stayed well, compared to 13 percent for responders. "Partial remission," Dr Thase emphasized, "is a very very high indicator of relapse."

Dr Thase observed that depression needs to be vigorously treated at high doses for adequate duration. Doctors need to ensure patient adherence, as two-thirds to three-quarters of patients do not take their antidepressants, he said. Doctors also have to measure patient outcomes, as "a simple finding of a symptom or two determines if a patient is in the response zone or the remission zone."

Significantly, Dr Thase said that remission needs to be the goal of the acute (initial) phase of treatment.

In the same symposium, Andrew Nierenberg MD of Harvard and Associate Director of the Mood Disorders Program at Mass General, polled the audience for how many measured depression in their patients in practice, and found about 10 percent. "I [began measuring] a few years ago," he told his audience, and the patients turned out to be "sicker than I thought." "I urge you to measure," he emphasized. "It will change your practice."

This is why response to treatment can be misleading:

At a Tuesday morning symposium on treatment-resistant depression, Holly Swartz MD of the University of Pittsburgh noted that a patient with a 30 Hamilton Depression score that is reduced by 50 percent (what constitutes a response) to 15 on the scale is "still very sick."

Nearly all antidepressant trials test for response rather than remission, but one company has recently thrown down the gauntlet in using remission as its criteria. A meta-analysis of eight studies conducted by Dr Thase published in last year’s British Journal of Psychiatry found remission rates of patients on Effexor to be 45 percent vs 35 percent for an SSRI vs 25 percent for a placebo over eight weeks.

Wyeth Pharmaceuticals, which manufactures Effexor, also released data at the APA annual meeting showing that 67 percent of those who remitted on Effexor stayed remitted over 12 months.

Another study measuring combination Serzone and a talking therapy called Cognitive Behavioral Analysis System of Psychotherapy (CBASP) was published in the New England Journal of Medicine, which found those on combination CBASP-Serzone did better (85 percent combined response-remission) than those on Serzone alone (55 percent response-remission) or CBASP alone (52 percent response-remission). Of the 85 percent responders on combination treatment, 42 percent remitted. (See article.)

Maurizio Fava MD of Harvard underscored why remission needs to be a goal by reminding his audience that one episode of depression results in a greater than 50 percent probability of recurrence. With two episodes, the risk is greater than 70 percent, and three or more depressions makes another a virtual certainty at more than 90 percent.

High antidepressant doses should be the rule. Paxil on 40 mg/day runs the risk of a 23 percent recurrence while 20 mg/day of the same drug puts patients at more than double the risk at 51 percent. The optimal length of continuation therapy should be four to six months, and indefinitely for greater risk patients, he said. Unfortunately, by week 10, 50 percent of patients stop taking antidepressants, either because of the side effects, or they feel they don’t need the medication, or they feel better, or they feel the meds aren’t working, or they forget to take them. Prozac Weekly, he pointed out, results in better compliance.

Please do whatever you can in your power to aim for remission, and make sure your doctor or psychiatrist or therapist will work with you to reach this essential goal.