Remission vs Response

At the end of May, I attended the American Psychiatric Association's annual meeting in Philadelphia, along with some 17,000 psychiatrists and mental health workers. Perhaps the major lesson to be learned from the entire APA meeting, one that was emphasized by a number of speakers in a variety of forums, was that remission needs to be the goal in treating depression, not just response.

"This is the outcome that should be targeted," Michael Thase MD of the University of Pittsburgh told a Sunday morning symposia, which meant "no symptoms" and a "return to functional self," corresponding to a Hamilton-17 Depression score of 7 or lower. Dr Thase cited a UK study that showed a 70 percent relapse over 15 months for those who merely responded on meds (ie a partial improvement in symptoms). In contrast, there was only a 20 percent relapse among the remitters on meds, a difference of 3.5 times.

The response/remission figures played out with patients in talking therapy, according to a University of Pittsburgh study. There, the relapse rate for remitted patients was 10 percent over one year vs a 50 percent relapse rate for the responders, a five times difference.

Over 10 years, 30 percent of remitters stayed well, compared to 13 percent for responders. "Partial remission," Dr Thase emphasized, "is a very very high indicator of relapse."

Dr Thase observed that depression needs to be vigorously treated at high doses for adequate duration. Doctors need to ensure patient adherence, as two-thirds to three-quarters of patients do not take their antidepressants, he said. Doctors also have to measure patient outcomes, as "a simple finding of a symptom or two determines if a patient is in the response zone or the remission zone."

Significantly, Dr Thase said that remission needs to be the goal of the acute (initial) phase of treatment.

In the same symposia, Andrew Nierenberg MD of Harvard and Associate Director of the Mood Disorders Program at Mass General, polled the audience for how many measured depression in their patients in practice, and found about 10 percent. "I [began measuring] a few years ago," he told his audience, and the patients turned out to be "sicker than I thought." "I urge you to measure," he emphasized. "It will change your practice."

This is why response to treatment can be misleading:

At a Tuesday morning symposia on treatment-resistant depression, Holly Swartz MD of the University of Pittsburgh noted that a patient with a 30 Hamilton Depression score that is reduced by 50 percent (what constitutes a response) to 15 on the scale is "still very sick."

Go To Page: 1 2