If This Is Hope, Then I'll Take Despair

The first of this week's STAR-D papers is the one the media bit on the hardest. The dominant message is that the paper by John Rush et al. shows that patients just need to keep switching meds until they find the anti-depressant for them. That assessment is not supported by the study itself (to its credit, the WaPo got this bit right).

The paper looked at 727 patients for whom Celexa didn't work. They were, then, given either Wellbutrin-SR, Zoloft or Effexor-XR for a period of 14 weeks. The paper explains that all the patients had extreme, long-term depression--some had been battling the illness for well over a decade. Almost half are unemployed as a result and almost half had no insurance coverage of any kind, not even Medicaid which you get if you are on disability. That's nasty. So were the results with the meds.

Twenty-one percent of Wellbutrin patients had symptoms remit, as did 18 percent of the Zoloft patients and 25 percent of Effexor patients. Keep in mind that this was over a 14-week trial, a short period of time for depression that will likely be with a patient for much of their lives. A one-fifth to one-fourth shot at remission (and about the same proportions for what docs call "response") is pretty slim, especially when it's your butt on the line.

The second paper examined another group of 565 patients. These are patients who took Celexa but had poor results. They continued taking Celexa and either added Wellbutrin or Buspar to their regime. Docs wanted to see what kind of results they got with adding a non-SSRI to an SSRI where an SSRI alone did not work. Both groups had 30 percent symptom remission over the course of the trial, or about as rotten an outcome as did the patients in the first paper.

None of this is what I would call hope, although NAMI painted it that way, and it isn't what I would call success. It's nice if it happens for you, but chances are that it won't. And, in the meantime, some of these same meds have awful side-effects. Effexor is the worst of this group in that regard.

The results are what I would call disappointing and further confirmation that no matter how much researchers like to waive their arms about how much we now know about the human brain and the biochemical roots of depression and that there's a special pill that'll set all that straight, we simply do not have an answer here. We have a treatment that barely works and for short periods of time. What we have is the failure of the psychopharmacological revolution--or at least of its rhetoric. We also have a failure of the media. But that's another story.

Full disclosure: I took Zoloft for a short period in the mid-1990s. It didn't do jack shit for me. It was as lame as the other SSRs I had taken. By the time Effexor later hit the market, I wanted nothing to do with a med that targeted the serotonin receptor. I took Wellbutrin for perhaps three years all told. It was largely side effect free, so I labored on with it, even though it wasn't a very strong anti-depressant. And then I just decided I was tired of spending money on something that only sorta-kinda worked, especially without any solid knowledge of what its long term effects might be on my body, and walked away from the purple pill.