Chronically Depressed? What to Do When Antidepressants Don't Work

The range of options includes cognitive behavioral therapy and brain stimulation techniques like ECT.

Last winter, confined to bed by intense sadness, exhaustion, and headaches, the University of Kansas student found herself considering suicide. Desperate after a years-long struggle with depression, she sought a treatment she had once viewed as extreme: electroconvulsive therapy. After a few sessions, "I literally went from almost unable to function—feeling suicidal—to a 180-degree change," she says.

The student, who still contends with depression, is one of the many people chronically in its grip who, disappointed by antidepressants, are finding some relief in therapies ranging from exercise to various forms of high-tech brain stimulation. Some 27 million Americans were taking an antidepressant in 2005, more than twice the number almost 10 years earlier, thanks largely to the arrival of Prozac and other effective antidepressants with fewer side effects. But a groundbreaking 2006 trial known as STAR*D revealed that about one third of people found total relief with their first drug, and around a third were not helped even after trying several drugs and combinations. ECT, which has been controversial since the days when it was performed without anesthesia and sometimes without proper consent, has evolved considerably in recent years; by inducing a seizure, it is thought to reset dysfunctional brain circuitry. It "is the most effective and rapidly acting treatment for severe depression," says Sarah Lisanby, a professor of clinical psychiatry at Columbia University Medical Center who is a leading brain stimulation researcher.

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Depressed Teens More Likely To Get Better With Switch To Combination Therapy

More than half of teenagers with the most debilitating forms of depression that do not respond to treatment with selective serotonin reuptake inhibitors (SSRIs) show improvement after switching to a different medication combined with cognitive behavioral therapy, researchers at UT Southwestern Medical Center and their colleagues in a multicenter study have found.

Dr. Graham Emslie, professor of psychiatry and pediatrics at UT Southwestern and chief of child and adolescent psychiatry at Children's Medical Center Dallas, was a principal investigator in the study appearing in the Journal of the American Medical Association.

Adolescents with treatment-resistant depression have unique needs, for which standard treatments do not always work. "If an adolescent hasn't responded to an initial treatment, go ahead and switch treatments," said Dr. Emslie. "Our results should encourage clinicians to not let an adolescent stay on the same medication and still suffer."

The 334 study participants suffered from depression on average for about two years. The teenagers involved exhibited moderate to severe major depressive disorder, many with suicidal ideation. Historically, these types of patients have the worst treatment outcomes.

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Trials in Obsessive Compulsive Disorder Highlight Group Therapy, Escitalopram, and Anticonvulsants: Presented at CPA

The latest research on the management of obsessive compulsive disorder (OCD) suggests that cognitive behaviour therapy (CBT) can be as effective in groups and in the office as it is in one-on-one sessions and in the home. Also, the antidepressant escitalopram and anticonvulsants topiramate and lamotrigine may play a more important therapeutic role than has previously been recognised.

Pratap Chokka, MD, Associate Clinical Professor, University of Alberta, Psychiatrist, Grey Nuns Hospital, Edmonton, Canada, presented the latest findings on the management of OCD here on November 17 at the 57th Annual Conference of the Canadian Psychiatric Association (CPA).

Currently, CBT is a mainstay of treatment for OCD. As a stand-alone treatment, it has been found in some studies to be as effective as antidepressants. While one-on-one CBT therapy was believed until recently to be the most effective option, 2007 data has revealed that, in fact, both individual and group therapy are effective. While response rates were faster with individual therapy, overall response rates were similar with both modalities. This is an important finding for a real world setting, where patients are often on waiting lists to receive CBT, said Dr. Chokka.

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Behavior therapy plus medication may help teens with depression and substance use disorders

The antidepressant fluoxetine combined with cognitive behavioral therapy appears as effective for treating depression among teens who also have substance use disorders as among those without substance abuse problems, according to a report in the November issue of Archives of Pediatrics & Adolescent Medicine, one of the JAMA/Archives journals.

“Adolescents with substance use disorders (SUDs) have higher rates of depression (15 percent to 24 percent) than adolescents in the general population,” the authors write as background information in the article. “Comorbid [co-occuring] depression is also associated with more severe substance abuse, poorer drug treatment outcomes and higher relapse rates.”

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Cognitive Behavioral Therapy Reduces Risks of Teen Antidepressant Use

The combination of fluoxetine (Prozac) and cognitive behavior therapy for depressed teens may accelerate treatment response and protect against suicidality.

In a randomized trial, combination therapy was not superior to fluoxetine or cognitive behavior therapy after 36 weeks, reported John S. March, M.D., M.P.H., of Duke here, and colleagues, in the October issue of Archives of General Psychiatry.

But a previously published analysis of the same patients, which showed an early advantage in response rate at 12 weeks with combination therapy (73% versus 62% and 48%), suggests that it may be a superior strategy, they said.

"Because accelerating symptom reduction by using medication is an important clinical outcome in psychiatry, as it is in other areas of medicine, use of fluoxetine should be made widely available, not discouraged," they wrote.

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Should Adolescent Patients With Depression Be Given Antidepressants?

The National Institute for Health and Clinical Excellence (NICE), UK, advocates antidepressants should only be given to adolescent patients with depression if accompanied with psychological therapy. A new study published in the British Medical Journal suggests SSRI treatment with cognitive behavioral therapy will most probably not improve outcomes for adolescent patients with moderate to severe depression.

The study contradicts what NICE has in its guidelines.

A BMJ editorial this week examines the evidence and explains what the implications might be for health care professionals treating adolescents with depression.

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STAR*D Depression Study Finds Cognitive Therapy Equivalent To Medication But Selected By Fewer Patients

In the federally funded Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, outcomes for cognitive therapy as a second-step treatment were not different from outcomes of medication therapy. However, random assignment in this STAR*D level was based on each patient's treatment preferences, and only 26 percent of the patients accepted cognitive therapy as an option. These findings are reported in two articles in the May issue of The American Journal of Psychiatry (AJP), the official journal of the American Psychiatric Association (APA).

The treatment results are presented in "Cognitive Therapy as a Second-Step Treatment: A STAR*D Report," by Michael E. Thase, M.D., of the University of Pittsburgh, and other STAR*D investigators. The patients in the second treatment step had discontinued citalopram in the first treatment phase, either because it was not effective for them or because the side effects were too burdensome.

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