Phase three offered the remaining subjects (those not reaching full recovery in phases one or two) other augmenters or switching possibilities. The final outcome was that 67 percent of subjects treated met criteria for full recovery. The one-year follow-up, however, showed that only 45 percent of the original sample remained in remission.
The STAR-D study didn’t include a placebo control and wasn’t an open study, meaning that it wasn’t blinded. However, it reflects both the type of patients commonly seen by most therapists (those with severe depression and complex comorbidity) and a sequential approach to medical treatment. Such a strategy clearly is indicated if the first treatment either fails or only provides partial relief. It’s again important to emphasize that in all registration trials, subjects are treated with only one drug.
Another clinically relevant feature to bear in mind when considering the results of the Kirsch metanalysis is that 91 percent of the studies reviewed lasted six weeks or less. In the treatment of depression, some patients respond to antidepressants during the first four to six weeks, but if augmentation or switching is done, this always requires more than six weeks. This is especially true if the goal is full recovery.
While treatment outcome results in both antidepressant medication and psychotherapy studies fall significantly short of full recovery for all patients treated, the truth is severe depression is difficult to treat. For depression, the following treatments have been empirically validated: cognitive therapy, interpersonal therapy for depression, behavior therapy, antidepressant medications, high intensity light therapy, exercise, and electroconvulsive therapy (ECT or shock therapy). Even with integrated approaches, many people experience partial recovery, but continue to have some lingering depressive symptoms.
The articles by Kirsch and Fournier, and the Newsweek story, present accurate data, but fail to mention sequential treatments. I believe this limits the generalizability of the results being reported. When complex research results are oversimplified in the media, readers may misinterpret the findings, and some people who might otherwise be helped may not seek treatment. In the case of depression this is especially unfortunate, given that the World Health Organization predicts that by the year 2020, depression will be the second leading cause of reduced life expectancy due to suicide and to a host of medical illnesses related to it, most notably heart disease.
Increasingly, mental health professionals are under scrutiny to choose treatments that have empirical support, but it’s also important for the profession not to be drawn in by sensationalized or distorted reporting of research findings. Without the appropriate critical discernment and appreciation for the nuances of clinical applications of research, empirical findings can often cause harm as well as helpful therapeutic guidance.
John Preston, Psy.D., ABPP, a professor at Alliant International University, is a neuropsychologist. He’s the author or coauthor of 21 books on topics such as psychopharmacology, neurobiology, and psychotherapy, including Handbook of Clinical Psychopharmacology for Therapists. Contact: firstname.lastname@example.org.
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