Preventing Learned Helplessness In Preventing Learned Helplessness In Depression Treatment Guideline UsersDepression Treatment Guideline Users

Douglas E. Jorenby, Ph.D.

Associate Professor

28 September 2005

DisclosuresDisclosures

No commercial supportSalary support from NIH, DOM,

UWMF, and RWJF

Learning ObjectivesLearning Objectives

Be able to select effective treatments congruent with the Depression Treatment Guideline

Access behavioral treatment with maximum efficiency

Case HistoryCase History

30-something White maleGood overall health, with some

evidence of stress reactivityNo current medicationsNo alcohol, caffeine, tobacco, or

recreational drug use

Significant HistorySignificant History

Previous depressive episode+ response to multi-drug

pharmacotherapy+ response to psychotherapySelf-initiated bibliotherapy

““I read that antidepressants are I read that antidepressants are no better than placebos.”no better than placebos.”

Be NICE Now….Be NICE Now….

National Institute for Health and Clinical Excellence (NICE) Guideline (2004)

“….antidepressants, in particular selective serotonin reuptake inhibitors, should be the first line treatment for moderate or severe depression.”

Methodological CritiqueMethodological Critique

Arbitrary “clinical importance” difference of 3 points on the Hamilton (HAM-D) score

Dichotomization of continuous variable into response/remission

Moncrieff J, Kirsch I. Efficacy of antidepressants in adults. BMJ 2005;331:155-9

Methodological CritiqueMethodological Critique

No gradient of effect from “moderate” (14-18) to “severe” (19-22) to “very severe” (>22)

Lack of true blinding in placebo-controlled studies

Publication bias

Moncrieff J, Kirsch I. Efficacy of antidepressants in adults. BMJ 2005;331:155-9

Methodological CritiqueMethodological Critique

Nonspecific response to drugs such as methylphenidate, benzodiazepines, and antipsychotics

Heterogeneity vs. ‘Affective fallacy’

Khan A, et al. J Clin Psychopharmacol 2002;22:40-5.Kramer PD. Listening to Prozac 1993.

Meta-Analytic EvaluationMeta-Analytic Evaluation

Data were all efficacy data submitted to the US FDA for the six most widely prescribed antidepressants approved 1987-1999

Published and unpublished results were utilized

Kirsch I, et al. Prevention & Treatment 2002;5:1-12.

Mean Improvement ObservedMean Improvement Observed

Kirsch I, et al. Prevention & Treatment 2002;5:1-12.

# of Trials N Drug Placebo Proportion

Fluoxetine 5 1,132 8.30 7.34 .89

Paroxetine 12 1,289 9.88 6.67 .68

Sertraline 3 779 9.96 7.93 .80

Venlafaxine 6 1,148 11.54 8.38 .73

Nefazodone 8 1,428 10.71 8.87 .83

Citalopram 4 1,168 9.69 7.71 .80

Balanced Placebo Solution?Balanced Placebo Solution?

Get

Told

Drug No Drug

Drug Drug + Placebo

Placebo

No Drug Drug Baseline

““Patients benefitting from an Patients benefitting from an antidepressant feel demeaned by antidepressant feel demeaned by media reports indicating that media reports indicating that antidepressants are little better antidepressants are little better than placebos.”than placebos.”

Parker G, et al. Br J Psychiatry 2003;183:102-04.

Non-Medication OptionsNon-Medication Options

In accord with the Guideline, psychotherapy may be used alone or in combination with pharmacotherapy

Cognitive Behavioral Therapy (CBT) has a significant evidence base of support for depression treatment

Admiral Hopper Was WrongAdmiral Hopper Was Wrong

Prior Authorization through Behavioral Health Consultation Service

1-800-683-2300 OR 282-8960Two-stage process

Different Leagues, Different RulesDifferent Leagues, Different Rules

P-Plus: All visits require prior authorization

Unity: Visits within the same clinic do not require prior authorization

Medical Assistance: All behavioral health services must be provided by Dane County Mental Health

Back To The CaseBack To The Case

Pt. decided against antidepressant therapy at present

Created a CBT treatment plan aimed at identifying and challenging “perfectionist” thoughts

Has already experienced reductions in stress responses at work

The Larger PictureThe Larger Picture

For many primary care patients, response to antidepressants may be quite modest

Placebo vs. Non-specific responseWhenever possible, listen to patient

preferences