Pharmacological treatment approaches

Topics: Selective serotonin reuptake inhibitor, Major depressive disorder, Serotonin Pages: 2 (522 words) Published: May 15, 2014
Pharmacological treatment approaches

It is widely accepted that at least one in three patients
with depression will not respond adequately to a series
of appropriate treatments.1 There have been several
approaches to defining this difficult-to-treat depression.
One recently developed proposal is the Maudsley staging
method — a points-based model of degrees of treatment
resistance, which takes into account details of the specific treatments employed and the severity and duration of
the depression.2 Another widely used and more
straightforward definition is the failure to respond to two
adequate trials of antidepressants from different
pharmacological classes.3
Here, we use a pragmatic definition of difficult-to-treat
depression — failure to respond to an adequate course
of a selective serotonin reuptake inhibitor (SSRI)
antidepressant. This was the definition used in the
Sequenced Treatment Alternatives to Relieve Depression
(STAR*D) trial in the United States,4 which was funded by
the National Institute of Mental Health and is the single
biggest study on sequenced treatment for depression and
investigated rates of improvement in patients who had
failed to respond to an SSRI. In this article, we draw
liberally on the findings of the STAR*D trial, as well as
other studies of difficult-to-treat depression.
STAR*D: a real-world study
The STAR*D trial used a series of treatment steps,
premised on an initial failure to achieve remission after an adequate course of an SSRI. This approach reflects the
reality of primary care and specialist treatment of
depression in Australia (and most countries), whereby
most patients who require antidepressants are initially
treated with an SSRI. The trial recruited “real-world”
patients with depression, including patients who are
usually excluded from formal randomised controlled trials
(RCTs), such as those with chronic symptoms, comorbid
psychiatric and physical disorders, and substance misuse....
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