star d changed our working definition of treatment resistance
Download
Skip this Video
Download Presentation
STAR*D Changed Our Working Definition of Treatment Resistance

Loading in 2 Seconds...

play fullscreen
1 / 11

STAR*D Changed Our Working Definition of Treatment Resistance - PowerPoint PPT Presentation


  • 156 Views
  • Uploaded on

People who are intolerant to drugs regardless of dosage OR People who receive vigorous dosing but receive inadequate benefit (ie, do not remit). STAR*D Changed Our Working Definition of Treatment Resistance. Either is a treatment failure. 2 failed treatments = treatment resistance.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' STAR*D Changed Our Working Definition of Treatment Resistance' - chava


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
star d changed our working definition of treatment resistance
People who are intolerant to drugs regardless of dosage

OR

People who receive vigorous dosing but receive inadequate benefit (ie, do not remit)

STAR*D Changed Our Working Definition of Treatment Resistance

Either is a treatment failure.

2 failed treatments = treatment resistance

Rush AJ, et al. Am J Psychiatry. 2006;163:1905-1917.

star d level 2 overview
4 switch options and 3 augment options

If someone had a clear medication intolerance or <25% decrease in symptom severity by week 9 on an adequate dose, then that person was encouraged to move to the next treatment level

Overall remission rate at Level 2 was 31%

1 in 4 people who switched treatments remitted in Level 2

1 in 3 people who augmented the citalopram treatment remitted in Level 2

It matters less which drug is chosen than how the drug is used

No advantages in switching patients in class, out of class, or switching to a dual-action antidepressant

Substantial pharmacologic differences in classes of drugs don’t translate into differences in efficacy

STAR*D Level 2 Overview

Rush AJ, et al. N Engl J Med. 2006;54:1231-1242.

remission rates by levels 1 by qids sr 16 5
Remission Rates by Levels1By QIDS-SR16 ≤5

Overall Remitted1

(To the nearest %)

(n)

Level

Level 11 (3671) 37

Level 21,2 (1439) 31

Switch (789)

Augment (650)

Level 33 (377) 14

Switch (235)

Augment (142)

Level 44 (109) 13

QIDS-SR16 = Quick Inventory of Depressive Symptomatology, Self-Rated

1. Rush AJ, et al. Am J Psychiatry. 2006;163:1905-1917. 2. Wisnieweski SR, et al. Am J Psychiatry. 2007;164:753-760. 3. Nierenberg AA, et al. Am J Psychiatry. 2006;163:1519-1530. 4. McGrath PJ, et al. Am J Psychiatry. 2006;163:1531-1541.

star d defining evidence for protocols level 3

L2 therapy + lithium

N = 69

L2 therapy + T3

N = 73

MRT

N = 114

NTP

N = 121

STAR*D Defining Evidence for Protocols—Level 3

Nonremitting or intolerant tofirst 2 prescribed medications

Level 3:

Level 3 options:

SWITCH OPTIONS

Randomized

AUGMENT OPTIONS

Randomized

RESULTS: 14% remission rate overall (QIDS-SR16<5 at exit)

Remission happened, on average, after 9.6 weeks

MRT = mirtazapine; NTP = nortriptyline; T3 = triiodothyronine.

Nierenberg AA, et al. Am J Psychiatry. 2006;163:1519-1530.

star d defining evidence for protocols level 4
STAR*D Defining Evidence for Protocols—Level 4

Nonremitting or intolerant to any Level 3 therapy

Level 4:

Level 4 options:

TCP

N = 58

VEN-XR+ MRT

N = 51

SWITCH OPTIONS

Randomized

RESULTS: 13% remission rate overall (QIDS-SR16< 5 at exit)

TCP = tranylcypromine; VEN-XR = venlafaxine extended release; MRT = mirtazapine.

McGrath PJ, et al. Am J Psychiatry. 2006;163:1531-1541.

cognitive therapy
Cognitive therapy (CT) is both an acceptable switch and an acceptable augmentation option in the 2nd step1

Benefit of CT as augmentation was slower (up to3 weeks) compared with augmenting with medication2

If time to response is of the essence, then CT may not be the best option2

Whether CT responders/remitters fare better in follow-up is to be analyzed2

CT was not as popular as expected (26% chose it), which limited these results’ statistical power1

Cognitive Therapy

1. Wisniewski SR, et al. Am J Psychiatry. 2007;164:753-760. 2. Thase ME, et al. Am J Psychiatry. 2007;164:739-752.

star d child study
1/3 of mothers with major depressive disorder had children with psychiatric symptoms1

The children’s symptoms eased when maternal depression remitted or at least responded (a 50% drop in symptoms)1

If the mother remained depressed, 17% of symptom-free children started manifesting Axis I symptoms1

As the mother improved, so did the child—measurably for 6 months; tapering after that2

Children of late-remitting mothers showed same improvements2

STAR*D-Child Study

1. Weissman MM, et al. JAMA. 2006;295:1389-1398. 2. Pilowsky DJ, et al. Am J Psychiatry. AJP in Advance. June 16, 2008.A1A:1-12.

ancillary study anxious depression
Ancillary Study—Anxious Depression

The less likely patients are to respond to step 1 and step 2 treatments

As anxiety symptoms with depression increase

The more likely they are to experience adverse effects

The more likely they are to have greater side effect burden

Nelson JC. Am J Psychiatry. 2008;165:297-299.

overall predictors of attrition
Black race

Younger age

Higher perceived functioning

Black race

Less education

Greater side effect burden

Hispanic ethnicity

More Axis 1 comorbidities

Overall Predictors of Attrition

Later attrition if …

Immediate attrition if …

Lower attrition if …

  • >1 MDD episode
  • Older age

Warden D, et al. Am J Psychiatry. 2007;164:1189-1197.

takeaway messages from levels 2 4
People with greater side effect burden prefer switching to a new medication vs augmenting1,2,3

People most amenable to cognitive therapy have more education and/or a family history of mood disorders3,4

People with 2 failed treatments will take longer to achieve remission (often 10–14 weeks)1

Treatment-resistant cases will have greater treatment intolerance and greater side effect burden5,6,7

T3 deserves consideration as an augment drug when 2 treatments fail5

MAOI administration should be left to specialists who have experience using this drug class7

Despite differences in presumed mechanism of action, patient outcomes did not differ significantly according to which drug(s) they took1,2,6

Takeaway Messages from Levels 2–4

1. Rush AJ, et al. Am J Psychiatry. 2006;163:1905-1917. 2. Rush AJ, et al. N Engl J Med. 2006;54:1231-1242.

3. Wisniewski SR, et al. Am J Psychiatry. 2007;164:753-760. 4. Thase ME, et al. Am J Psychiatry. 2007;164:739-752. 5. Nierenberg AA, et al. Am J Psychiatry. 2006;163:1519-1530. 6. Rush AJ. Am J Psychiatry. 2007;164:201-204.7. McGrath PJ, et al. Am J Psychiatry. 2006;163:1531-1541.

suggested readings
Suggested Readings
  • Rush AJ, Trievdi NJ, Wisniewski SR, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry. 2006;163:1905-1917.
  • Rush AJ, Trivedi MH, Wisniewski SR, et al. Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression. N Engl J Med. 2006;54:1231-1242.
  • Wisniewski SR, Fava M, Trivedi MH, et al. Acceptability of second-step treatments to depressed outpatients: a STAR*D report. Am J Psychiatry. 2007;164:753-760.
  • Thase ME, Friedman ES, Biggs MM, et al. Cognitive therapy versus medication in augmentation and switch strategies as second-step treatments: a STAR*D report. Am J Psychiatry. 2007;164:739-752.
  • Nierenberg AA, Fava M, Trivedi MH, et al. A comparison of lithium and T3 augmentation following two failed medication treatments for depression: a STAR*D report. Am J Psychiatry. 2006;163:1519-1530.
  • Rush AJ. STAR*D: what have we learned? Am J Psychiatry. 2007;164:201-204.
  • McGrath PJ, Stewart JW, Fava M, et al. Tranylcypromine versus venlafaxine plus mirtazapine following three failed antidepressant medication trials for depression: a STAR*D report. Am J Psychiatry. 2006;163:1531-1541.
  • Warden D, Trivedi MH, Davis L, et al. Predictors of attrition during initial (citalopram) treatment for depression: a STAR*D report. Am J Psychiatry. 2007;164:1189-1197.
  • Pilowsky DJ, Wickramaratne P, Tag M, et al. Children of depressed mothers 1 year after initiation of maternal treatment: findings from the STAR*D study. Am J Psychiatry. AJP in Advance June 16, 2008:AiA1-12.
  • Ladsen L. STAR*D study leaders at UT Southwestern test two-drug approach to depression in new CO-MED trial. Press release. July 22, 2008. http://www.eurekalert.org/pub_releases/2008-07/usmc-ssl072108.php. Accessed August 10, 2008.
ad