Preventing Learned Helplessness In Depression Treatment Guideline Users

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Preventing Learned Helplessness In Depression
Treatment Guideline Users

• Douglas E. Jorenby, Ph.D.
• Associate Professor
• 28 September 2005

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Disclosures

• No commercial support
• Salary support from NIH, DOM, UWMF, and RWJF

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Learning Objectives

• Be able to select effective treatments congruent
  with the Depression Treatment Guideline
• Access behavioral treatment with maximum
  efficiency

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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

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Significant History

• Previous depressive episode
• response to multi-drug pharmacotherapy
• response to psychotherapy
• Self-initiated bibliotherapy

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I read that antidepressants are no better than
placebos.

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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.

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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 2005331155-9
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Methodological Critique

• No gradient of effect from moderate (14-18) to
  severe (19-22) to very severe (gt22)
• Lack of true blinding in placebo-controlled
  studies
• Publication bias

Moncrieff J, Kirsch I. Efficacy of
antidepressants in adults. BMJ 2005331155-9
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Methodological Critique

• Nonspecific response to drugs such as
  methylphenidate, benzodiazepines, and
  antipsychotics
• Heterogeneity vs. Affective fallacy

Khan A, et al. J Clin Psychopharmacol
20022240-5. Kramer PD. Listening to Prozac
1993.
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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
200251-12.
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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 4 1,168 9.69 7.71 .80
Kirsch I, et al. Prevention Treatment
200251-12.
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Balanced Placebo Solution?
Get Get Get
Told Drug No Drug
Told Drug Drug Placebo Placebo
Told No Drug Drug Baseline
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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 2003183102-04.
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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

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Admiral Hopper Was Wrong

• Prior Authorization through Behavioral Health
  Consultation Service
• 1-800-683-2300 OR 282-8960
• Two-stage process

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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

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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

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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