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Dr. Bob is Robert Hsiung, MD,
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Posted by seldomseen on January 4, 2008, at 6:27:20
In reply to What have we learned from the STAR*D study?, posted by SLS on January 4, 2008, at 5:42:45
THAT is a VERY interesting read indeed!
Personally, I wish the study made it easier for subjects to enter cognitive therapy as an adjunct to medication. I believe a lot of studies indicate that the right kind of therapy plus pills is better.
Also, one of the complicating issues in depression is that there are several different KINDS of depression and there may not be "one pill treats all" type situation.
We've definately encountered this complication when it comes to cancer treatment and we've learned that it's all about getting the right drug with the right cancer.
I suspect that might be true with depression as well.
Anyway, interesting read no doubt.
I thank god everyday that I responded to prozac.
Seldom.
Posted by Phillipa on January 4, 2008, at 10:36:47
In reply to Re: What have we learned from the STAR*D study?, posted by seldomseen on January 4, 2008, at 6:27:20
Yes you're definitely fortunate to be responsieve to one pill prozac. That's great. Love Phillipa ps thank's Scott for the study.
Posted by Jamal Spelling on January 4, 2008, at 15:57:39
In reply to What have we learned from the STAR*D study?, posted by SLS on January 4, 2008, at 5:42:45
LOL! While you were away, many arguments were had over the STAR*D study...
Posted by Jamal Spelling on January 4, 2008, at 15:59:05
In reply to Re: What have we learned from the STAR*D study?, posted by Jamal Spelling on January 4, 2008, at 15:57:39
Posted by LostBoyinNCBecksDark on January 4, 2008, at 16:43:30
In reply to What have we learned from the STAR*D study?, posted by SLS on January 4, 2008, at 5:42:45
STAR*D has been one of the few decent studies psychiatry has conducted. STAR*D proved that SSRIs (Celexa) only work one third of the time...a dismal remission rate. STAR*D also confirmed what many mental patients have known for decades, but many psychiatrists have refused to acknowledge. And that is, remission rates for clinical depression are poor.
STAR*D confirmed that psychiatry is a sorry excuse for treating severe mental illness and that the focus needs to be more on hard science approaches. psychiatry needs to be formally merged into Neurology and also with sleep medicine to get real results.
NIMH should be formally merged with NIH. There should be no split between the "mind" and the body.
I spit on psychiatry! I also spit on anti-psychiatry! They are both wrong.
Eric, AKA LostBoyinNC
Posted by gardenergirl on January 4, 2008, at 17:08:14
In reply to Re: STAR*D confirmed what patients already knew, posted by LostBoyinNCBecksDark on January 4, 2008, at 16:43:30
Do me a favor, eh? Listen to Jim Croce before you meet up with Superman or the Lone Ranger.
gg
Posted by Jamal Spelling on January 4, 2008, at 17:17:47
In reply to Let the fighting begin! (nm), posted by Jamal Spelling on January 4, 2008, at 15:59:05
That word... STAR*D... it's like a curse word, or trigger, or something. It's even got an asterisk in it! You just mention it, and an argument is sure to follow.
We can all save ourselves this argument by referring to any of the previous 83,656,823 arguments that have been had over STAR*D.
Posted by Deputy Dinah on January 4, 2008, at 17:39:56
In reply to Re: STAR*D confirmed what patients already knew, posted by LostBoyinNCBecksDark on January 4, 2008, at 16:43:30
> I spit on psychiatry! I also spit on anti-psychiatry! They are both wrong.
Please respect the views of others even if you think they're wrong.
You've been warned before to follow site guidelines so I'm going to have to block you from posting. I'll set the block length at twice the length of the former block length and ask Dr. Bob to review it.
Follow-ups regarding these issues, as well as replies to the above posts, should of course themselves be civil.
Dr. Bob is always free to override deputy decisions. His email is on the bottom of each page. Please feel free to email him if you believe this decision was made in error.
Dinah, acting as deputy to Dr. Bob
Posted by Deputy Dinah on January 4, 2008, at 17:42:33
In reply to Let the fighting begin! (nm), posted by Jamal Spelling on January 4, 2008, at 15:59:05
Lively and respectful discussion is quite welcome.
Let's keep it civil please?
Posted by Sigismund on January 4, 2008, at 17:47:24
In reply to Re: STAR*D confirmed what patients already knew, posted by LostBoyinNCBecksDark on January 4, 2008, at 16:43:30
I rather liked this.....
>the focus needs to be more on hard science approaches. psychiatry needs to be formally merged into Neurology [...and more besides]
>There should be no split between the "mind" and the body.
Posted by SLS on January 4, 2008, at 18:17:22
In reply to Re: STAR*D confirmed what patients already knew, posted by LostBoyinNCBecksDark on January 4, 2008, at 16:43:30
Hi.
> STAR*D has been one of the few decent studies psychiatry has conducted. STAR*D proved that SSRIs (Celexa) only work one third of the time...
This study proves that, using the limited algorithm chosen, 70% of people can be brought to full remission. Can you imagine how many permutations of drug combinations can be offered if a 100% success rate was the goal? Maybe someone can produce a factorial using all the drugs found on my Psychiatric Drugs Chart. I have yet to add a few more.
In my opinion, the STAR*D is close to being an irrelevant study if you want to know how many people can be brought to full remission employing unrestricted algorithms using the entire psychotropic arsenal.
From the STAR*D review:
"• For patients who present with major
depressive disorder, STAR*D suggests that
with persistence and aggressive yet feasible
care, there is hope: after one round, approximately
30% will have a remission; after two
rounds, 50%; after three rounds, 60%; and
after four rounds, 70%."A 70% success rate is far from being "poor".
Do you suppose the success rate would be more than 70% if any and all drugs and drug combinations were used?
The STAR*D study has weaknesses that some people seem to feel argues in favor of a demonstration of poor efficacy. On the contrary, this study proves that the efficacy rate using a handful of drugs is 70%. That stands as a fair prognosis for an individual stricken with Major Depressive Disorder. I believe that the true rate of remission must be higher when there are no restrictions on the treatments available.
As an aside, the NIH stands for "The National Institutes of Health". Notice the use of the plural form of the word "institutes". Each categorization of illness is formally assigned to and named an institute. The NIH is comprised of many individual institutes. There is no arbitrary dichotomy of mind versus body.
- Scott
Posted by Phoenix1 on January 4, 2008, at 18:54:15
In reply to Re: STAR*D confirmed what patients already knew » LostBoyinNCBecksDark, posted by SLS on January 4, 2008, at 18:17:22
> Hi.
>
> > STAR*D has been one of the few decent studies psychiatry has conducted. STAR*D proved that SSRIs (Celexa) only work one third of the time...
>
> This study proves that, using the limited algorithm chosen, 70% of people can be brought to full remission. Can you imagine how many permutations of drug combinations can be offered if a 100% success rate was the goal? Maybe someone can produce a factorial using all the drugs found on my Psychiatric Drugs Chart. I have yet to add a few more.
>
> In my opinion, the STAR*D is close to being an irrelevant study if you want to know how many people can be brought to full remission employing unrestricted algorithms using the entire psychotropic arsenal.
>
> From the STAR*D review:
>
> "• For patients who present with major
> depressive disorder, STAR*D suggests that
> with persistence and aggressive yet feasible
> care, there is hope: after one round, approximately
> 30% will have a remission; after two
> rounds, 50%; after three rounds, 60%; and
> after four rounds, 70%."
>
> A 70% success rate is far from being "poor".
>
> Do you suppose the success rate would be more than 70% if any and all drugs and drug combinations were used?
>
> The STAR*D study has weaknesses that some people seem to feel argues in favor of a demonstration of poor efficacy. On the contrary, this study proves that the efficacy rate using a handful of drugs is 70%. That stands as a fair prognosis for an individual stricken with Major Depressive Disorder. I believe that the true rate of remission must be higher when there are no restrictions on the treatments available.
>
> As an aside, the NIH stands for "The National Institutes of Health". Notice the use of the plural form of the word "institutes". Each categorization of illness is formally assigned to and named an institute. The NIH is comprised of many individual institutes. There is no arbitrary dichotomy of mind versus body.
>
>
> - ScottI agree on most points. But that 30% remission on ARM 1 is meaningful, because that is the standard of care when you go to most GP's for depression. Instead of augmenting or moving to something different, most GP's will just prescribe a second SSRI after the initial treatment failure. I think STAR*D provides the framework for a valuable algorithm for GP's to follow instead of blindly prescribing SSRI after SSRI without improvement like some GP's do. It's not perfect, but the data is valuable.
Phoenix1
Posted by yxibow on January 4, 2008, at 19:33:39
In reply to What have we learned from the STAR*D study?, posted by SLS on January 4, 2008, at 5:42:45
I thought we collectively beat this back and forth not that long ago. Let's not do it again. Just my opinion, everyone is entitled to their voice.
If you ask me, its like the CATIE study in a way. Older line drugs are just as good as new drugs, but at what price glory and what side effects?
Anyhow. I will retire from the fray.
Posted by seldomseen on January 4, 2008, at 19:49:34
In reply to Re: STAR*D confirmed what patients already knew » LostBoyinNCBecksDark, posted by SLS on January 4, 2008, at 18:17:22
Can you imagine if there were a 70% remission rate in Cancer treatment?
People would be dancing in the streets!
Posted by Cecilia on January 4, 2008, at 21:04:29
In reply to Re: STAR*D confirmed what patients already knew » SLS, posted by seldomseen on January 4, 2008, at 19:49:34
> Can you imagine if there were a 70% remission rate in Cancer treatment?
>
> People would be dancing in the streets!Yes, but the people who don't respond to cancer treatments die and their suffering is over. Those of us in the 30% who don't respond to depression treatments continue suffering for the rest of our lives. Yes, we can kill ourselves, but many of us are too afraid. Cecilia
Posted by linkadge on January 4, 2008, at 22:14:04
In reply to Re: STAR*D confirmed what patients already knew » seldomseen, posted by Cecilia on January 4, 2008, at 21:04:29
That 70% get better for a measurable period of time doesn't mean that it was necessarily the drugs that made this happen, nor does it mean that one won't relapse. I don't think the STAR*D used a placebo arm, which mystifies which routes really lead to recovery. So these studies certainly don't say that modern medical science can eliminate 70% of depression or anything.
Linkadge
Posted by Racer on January 5, 2008, at 2:13:15
In reply to Re: STAR*D confirmed what patients already knew, posted by linkadge on January 4, 2008, at 22:14:04
> That 70% get better for a measurable period of time doesn't mean that it was necessarily the drugs that made this happen, nor does it mean that one won't relapse. I don't think the STAR*D used a placebo arm, which mystifies which routes really lead to recovery. So these studies certainly don't say that modern medical science can eliminate 70% of depression or anything.
>
> LinkadgeOn the other hand, it was a more "real world" type of study and there are benefits to that. Personally, I was impressed by the concept for that reason. What's more, I think that the study was set up to look at something different from the standard double-blind placebo controlled study, and was valid for that purpose. The article addressed some of the weaknesses of the study, as well. I always like to see that sort of balance in articles such as this.
I'd like more information about this study, particularly the numbers. Does anyone know if those are available and where?
By the way, thanks to Scott for posting this. I hadn't taken the time to read much about the study, and I'm glad I did.
Posted by SLS on January 5, 2008, at 5:45:42
In reply to Re: STAR*D confirmed what patients already knew » SLS, posted by Phoenix1 on January 4, 2008, at 18:54:15
> > Hi.
> >
> > > STAR*D has been one of the few decent studies psychiatry has conducted. STAR*D proved that SSRIs (Celexa) only work one third of the time...
> >
> > This study proves that, using the limited algorithm chosen, 70% of people can be brought to full remission. Can you imagine how many permutations of drug combinations can be offered if a 100% success rate was the goal? Maybe someone can produce a factorial using all the drugs found on my Psychiatric Drugs Chart. I have yet to add a few more.
> >
> > In my opinion, the STAR*D is close to being an irrelevant study if you want to know how many people can be brought to full remission employing unrestricted algorithms using the entire psychotropic arsenal.
> >
> > From the STAR*D review:
> >
> > "• For patients who present with major
> > depressive disorder, STAR*D suggests that
> > with persistence and aggressive yet feasible
> > care, there is hope: after one round, approximately
> > 30% will have a remission; after two
> > rounds, 50%; after three rounds, 60%; and
> > after four rounds, 70%."
> >
> > A 70% success rate is far from being "poor".
> >
> > Do you suppose the success rate would be more than 70% if any and all drugs and drug combinations were used?
> >
> > The STAR*D study has weaknesses that some people seem to feel argues in favor of a demonstration of poor efficacy. On the contrary, this study proves that the efficacy rate using a handful of drugs is 70%. That stands as a fair prognosis for an individual stricken with Major Depressive Disorder. I believe that the true rate of remission must be higher when there are no restrictions on the treatments available.
> >
> > As an aside, the NIH stands for "The National Institutes of Health". Notice the use of the plural form of the word "institutes". Each categorization of illness is formally assigned to and named an institute. The NIH is comprised of many individual institutes. There is no arbitrary dichotomy of mind versus body.
> I agree on most points. But that 30% remission on ARM 1 is meaningful, because that is the standard of care when you go to most GP's for depression.That's pretty much why I wouldn't go to a GP for a bowl resection. You need a specialist in the psychiatric field to provide knowledgeable treatment.
> Phoenix1
Risen from the ashes first?
:-)
- Scott
Posted by Cecilia on January 5, 2008, at 5:51:40
In reply to Re: STAR*D confirmed what patients already knew, posted by linkadge on January 4, 2008, at 22:14:04
Given the high placebo response in most AD trials, a study without a placebo wing does seem pretty useless. On the other hand, you can probably assume that people who failed the first 3 trials and made it to the 4th are probably not placebo responders. Though on the other hand, I do think there probably IS a high placebo response to MAOI's because by the time people get to them they are expecting miracles. They read about how wonderful they are, they may have to search high and low to find a doctor who will prescribe them, they sacrifice favorite foods, all in hope of the miracle. (Unfortunately many, like me, definitely not a placebo responder, find no miracle). Cecilia
.
Posted by SLS on January 5, 2008, at 5:54:33
In reply to Re: STAR*D, posted by yxibow on January 4, 2008, at 19:33:39
Hi yxibow.
I should hope that you folks have been civil to each other in my absence. If there can be no debate, I doubt there can be much synthesis. Of course, I might not choose to comment further on an issue I do not yet understand fully. I am reading one post at a time in order, so I have yet to see someone attack me personally.
By the way - WHAT IS THE ISSUE?
I have no regrets if my post ended up starting a fight between other individuals - if that's the only way they can communicate.
Let's see if I can practice what I preach.
- Scott
Posted by Cecilia on January 5, 2008, at 6:04:46
In reply to Re: STAR*D confirmed what patients already knew, posted by Racer on January 5, 2008, at 2:13:15
The other thing I don't understand about the study is where they found these depressed people who hadn't already tried these very common drugs already. They certainly didn't include anybody with chronic depression or they would have already tried them. So they probably got much better results than in the "real world". Cecilia
Posted by SLS on January 5, 2008, at 6:27:57
In reply to Re: STAR*D confirmed what patients already knew » seldomseen, posted by Cecilia on January 4, 2008, at 21:04:29
Hi Cecilia.
> > Can you imagine if there were a 70% remission rate in Cancer treatment?
> > People would be dancing in the streets!
> Yes, but the people who don't respond to cancer treatments die and their suffering is over. Those of us in the 30% who don't respond to depression treatments continue suffering for the rest of our lives.----------------------------------------------------
I bet my doctor can get you well. He is allowed to use, among other things:
adrafinil
amantadine
amisulpride
amitriptyline
amoxapine
amphetamine
aripiprazole
buprenorhine
bupropion
buspirone
carbemazepine
citalopram
clomipramine
desipramine
dothiepin
doxepin
duloxetine
escitalopram
fluoxetine
fluvoxamine
fluvoxamine
gabapentin
galantamine
imipramine
indalpine
isocarboxazid
lamotrigine
levetiracetam
levoprotiline
lithium
lofepramine
lofepramine
maprotiline
memantine
methylphenidate
methylphenidate
mexiletine
mianserin
milnacipran
milnacipran
mirtazapine
moclobemide
modafinil
naltrexone
nefazodone
nifedipine
nimodipine
nisoxetine
nortriptyline
nortriptyline
olanzapine
opipramol
oxcarbazepine
paroxetine
pergolide
phenelzine
phenytoin
pindolol
piribedil
pirlindole
pramepexole
protriptyline
quetiapine
reboxetine
risperidone
rolipram
ropinerole
selegiline
selegiline
sibutramine
sulpiride
tianeptine
toloxatone
tomoxetine
topiramate
tramadol
tranylcypromine
trazodone
trimipramine
valproate
venlafaxine
verapamil
vigabatrin
viloxazine
viqualine
ziprasidone
zonisamide
What do you think? Do you think you have tried *everything*, including combinations of 2-6 drugs?
> Yes, we can kill ourselves, but many of us are too afraid.
Or too depressed. Some people are so severely depressed, that they don't have the energy or cognitive resources to kill themselves. That's why the second through forth weeks of antidepressant treatment must be monitored so closely by a specialist (psychiatrist). It can be a dangerous time. Sometimes, as someone is responding well to a drug, they become more activated and more able to act. Also, let us not forget that antidepressant are powerful and little understood, as is the brain. Antidepressants can make certain people biologically suicidal or more severely depressed. We don't know why or how to predict it. Again, this is something that a psychiatrist is responsible for acknowledging when treating affective disorders.
- Scott
Posted by SLS on January 5, 2008, at 6:32:26
In reply to Re: STAR*D confirmed what patients already knew » linkadge, posted by Cecilia on January 5, 2008, at 5:51:40
> Given the high placebo response in most AD trials, a study without a placebo wing does seem pretty useless.
Yes. Many investigators are coming to this conclusion. Using comparator drugs with established efficacy saves a lot of time. Is it ethical at this point in the evolution of psychiatric drugs to treat suffering with nothing but sugar pills?
- Scott
Posted by SLS on January 5, 2008, at 6:43:29
In reply to Re: STAR*D confirmed what patients already knew, posted by Cecilia on January 5, 2008, at 6:04:46
> The other thing I don't understand about the study is where they found these depressed people who hadn't already tried these very common drugs already. They certainly didn't include anybody with chronic depression or they would have already tried them. So they probably got much better results than in the "real world". Cecilia
"Entry criteria were broad and inclusive
Patients had to:
• Be between 18 and 75 years of age
• Have a nonpsychotic major depressive
disorder, identified by a clinician and confirmed
with a symptom checklist based on
the Diagnostic and Statistical Manual,
fourth edition revised,20 and for which
antidepressant treatment is recommended
• Score at least 14 on the 17-item Hamilton
Rating Scale for Depression (HAMD17)
21
• Not have a primary diagnosis of bipolar
disorder, obsessive-compulsive disorder, or
an eating disorder, which would require a
different treatment strategy, or a seizure
disorder (which would preclude bupropion
as a second-step treatment)."
The investigators made no other exclusions. Unless I missed it, and with my reading skills so impaired, this is entirely possible, there is no mention of excluding subjects whom were previously treated with psychotropic drugs. The subjects studied seems to be representative of the general population - the objective of the study.
"FEW DIFFERENCES BETWEEN
PSYCHIATRIC, PRIMARY CARE PATIENTS
The patients seen in primary care clinics were
surprisingly similar to those seen in psychiatric
clinics.27,28 The two groups did not differ in
severity of depression, distribution of severity
scores, the likelihood of presenting with any of
the nine core criteria of a major depressive
episode, or the likelihood of having a concomitant
axis I psychiatric disorder in addition
to depression (about half of participants
in each setting had an anxiety disorder).
Recurrent major depressive disorders were
common in both groups, though more so in
psychiatric patients (78% vs 69%, P < .001),
while chronic depression was more common
in primary care than in psychiatric patients
(30% vs 21%, P < .001). Having either a
chronic index episode (ie, lasting > 2 years) or
a recurrent major depressive disorder was common
in both groups (86% vs 83%, P = .0067).
That said, primary care patients were
older (44 years vs 39 years, P < .001), more of
them were Hispanic (18% vs 9%, P < .001),
and more of them had public insurance (23%
vs 9%, P < .001). Fewer of the primary care
patients had completed college (20% vs 28%,
P < .001), and the primary care patients tended
to have greater medical comorbidity.
Psychiatric patients were more likely to have
attempted suicide in the past and to have had
their first depressive illness before age 18"
From: "The STAR*D study: Treating depression in the real world"- Scott
Posted by bulldog2 on January 5, 2008, at 9:54:58
In reply to What have we learned from the STAR*D study?, posted by SLS on January 4, 2008, at 5:42:45
> What have we learned from the STAR*D study?
>
> What are its strengths and weaknesses?
>
>
> "The STAR*D study: Treating depression in the real world"
>
> http://sl.schofield3.home.att.net/medicine/the_star_d_study_real_world.pdf
>
>
> - ScottDid this study include the number of people who drop out of treatment because of side effects? That seems to be a big problem especially on this board. For instance how many people will not try an maoi because of all the restrictions even though they may be very effective.
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Dr. Bob is Robert Hsiung, MD,
[email protected]
Script revised: February 4, 2008
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