STARD & TARD

Question 1

How is treatment-resistant depression defined?

Answer 1

MDD Patient who has failed at least two trials of antidepressant agents

Question 2

Results and info about the STAR*D trial

Answer 2

A prospective study ITP partially randomized
- designed to describe and compare acute and longer-term treatment outcomes associated with sequenced treatment alternatives to relieve depression

Inclusion criteria:

• non psychotic MDD
• 18-75 yrs
• not pregnant or breast feeding
• naive to treatments in the first two steps

Exclusion criteria

• other major mental diagnosis
• has a substance abuse disorder where they need to be detoxed

Outcome measures:

• response = 50% reduction in QIDS-SR16 score from baseline
• remission = total QIDS-SR16 score of <5
• relapse = QIDS-SR16 score >11 after entering the f/u phase
• treatment intolerance = leaving the treatment step before 4 weeks from any reason

Results:

• level 1 remission = 37%
• level 2 remission = 31%
• level 3 remission = 14%
• level 4 remission = 13%
• level 1 drop out = 21%
• level 2 drop out = 30%
• level 3 drop out = 42%

Question 3

What 3 questions should you think about if a patient is not responding to a treatment for depression?

Answer 3

1) are they taking the medication?

2) have they taken it for long enough?
- needs at very least 1 month at adequate dose
- failure cant be determined unless the medication is taken for at least a month

3) is it primary depression?
- if secondary, is the cause of depression being managed properly?

Question 4

Overall goal of depression treatment

Answer 4

Remission for at least 2 months, if not more

the more symptoms = more severe and need to be more proactive

Question 5

Clinical implications for treatment of depression based on STAR*D study

Answer 5

1st line = SSRI and/or CBT

Switch to another monotherapy and a different class if it doesnt work 
- if it does partially work and handling ADRs well, can augment instead (increase dose or add a combo therapy) 

Try ECT and ketamine if fails multiple therapies

Question 6

Electroconvulsive therapy

Answer 6

Uses electrical currents to produce generalized seizures while the patient is under anesthesia

Has been used since 1939 and has been refined overtime

Is very good in treatment resistant depression

• usually requires 6-12 rounds for remission of symptoms
• one of the most safe procedures for general anesthesia procedures

Contraindications are few:

• recent MI/stroke or active bleeding
• uncontrolled HTN
• presence of increased intracranial pressure
• presence of cochlear implants

Safe in pregnancy

Question 7

What was the goal of the STAR*D trial

Answer 7

Assess effectiveness of depression treatments in patients with MDD.

4 levels that were used to test most appropriate treatments

Conclusions:

• if a first line treatment with SSRI fails, 1/4 people who choose to switch to another medication designed to treat depression (regardless of the class of medication) will get better.
• it is not sure if switching medications or adding another medication is better (base it off ADR profile and patient adherence)
• adding T3 to new medication has some preliminary positives associated with it (however must monitor to make sure patient can tolerate)
• patients who required several different treatments to become symptom-free are more likely to relapse
• while patients with TRD can get better, the odds of getting better decrease with each failed therapy tried.
• MDD medication should be used for at least 6 weeks (ideally up to 10) before considering switching

Question 8

What is treatment refractory depression?

Answer 8

Patient has had multiple episodes of depression that don’t respond to many treatment options