Transcript Preventing Learned Helplessness In Depression Treatment

Preventing Learned Helplessness In
Depression Treatment Guideline Users
Douglas E. Jorenby, Ph.D.
Associate Professor
28 September 2005
Disclosures
No commercial support
 Salary support from NIH, DOM,
UWMF, and RWJF

Learning Objectives
Be able to select effective treatments
congruent with the Depression
Treatment Guideline
 Access behavioral treatment with
maximum efficiency

Case History
30-something White male
 Good overall health, with some
evidence of stress reactivity
 No current medications
 No alcohol, caffeine, tobacco, or
recreational drug use

Significant History
Previous depressive episode
 + response to multi-drug
pharmacotherapy
 + response to psychotherapy
 Self-initiated bibliotherapy

“I read that antidepressants are no
better than placebos.”
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 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 Critique
No gradient of effect from
“moderate” (14-18) to “severe” (1922) to “very severe” (>22)
 Lack of true blinding in placebocontrolled studies
 Publication bias

Moncrieff J, Kirsch I. Efficacy of antidepressants in adults. BMJ 2005;331:155-9
Methodological 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 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 Published and unpublished results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 Observed
# 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
1,168
9.69
7.71
.80
4
Kirsch I, et al. Prevention & Treatment 2002;5:1-12.
Balanced Placebo Solution?
Get
Drug
No Drug
Drug
Drug +
Placebo
Placebo
No Drug
Drug
Baseline
Told
“Patients benefitting from an
antidepressant feel demeaned by
media reports indicating that
antidepressants are little better
than placebos.”
Parker G, et al. Br J Psychiatry 2003;183:102-04.
Non-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 Wrong
Prior Authorization through
Behavioral Health Consultation
Service
 1-800-683-2300 OR 282-8960
 Two-stage process

Different 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 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 Picture
For many primary care patients,
response to antidepressants may be
quite modest
 Placebo vs. Non-specific response
 Whenever possible, listen to patient
preferences
