STAR*D was a historic, large-scale research trial that found people don’t get better in depression treatment as quickly, or as easily, as previously thought. It showed, basically, that people often needed to change medications or treatment approaches to gain remission of their depressive symptoms.
In the American Journal of Psychiatry letters section earlier this month, researchers suggested that perhaps complete remission isn’t the ideal goal for everyone in treatment. And that the advocacy of even more complex treatment regimens for treatment-resistant patients (e.g., prescribing multiple types and doses of psychiatric medications at the same time) is potentially dangerous and with little research basis.
John Rush’s, one of STAR*D’s authors, replied basically going back and forth in his agreement with the researchers.
Furious Seasons published its own perspective on this interchange, as well as some interesting comments to the entry. Philip at Furious Seasons really seemed to have had an issue with psychiatry/psychology setting “complete remission” as a reasonable treatment goal for most people.
Is complete remission of depressive symptoms (or, in fact, symptoms for any mental disorder) an achievable, realistic goal for most? STAR*D showed that 67% of the people in the study achieved remission, after trying multiple treatments. And STAR*D has been commended as a “real-world” research study — that is, the researchers made efforts not to try and control every possible variable in the dozens of clinical studies it drew its patients from.
It should be noted what “complete remission” really means in this context, too. The researchers defined “complete remission” of depression in a standard manner — scoring 7 or less on the Hamilton Rating Scale of Depression (HSRD17), which is a clinician-administered rating scale. Scoring 7 or less means that you can still have depressive feelings, it just means those feelings are within normal range and no longer clinically significant. So “complete remission” in this context does not mean, “no depressive feelings whatsoever.” It just means any depressive feelings the patient now has are clinically insignificant.
One of the possible problems with STAR*D is that it chose not to use a patient self-report measure of depression, such as the Beck Depression Inventory (BDI). I’m always a little critical of studies that choose to use clinician-based measures over patient-based measures (why not use both and be certain?), because it means we’re measuring outcomes based upon the clinicians’ criteria (judgment and biases), not the patients’. You could very well have clinicians rating a person as no longer being clinically depressed, but the patient’s self-report could say otherwise.
But we still have one-third of people, after trying multiple treatment strategies, feeling significantly depressed. We have to acknowledge the reality of today’s current modern treatments leave a lot of people still with their depression.
The reality today is that few treatment plans filled out by clinicians with their clients say, “Goal: Complete remission of depression.” Instead, they are far more likely to say, “Goal: Reduce daily depressive feelings by 10% as measured by self-report on the BDI” or something similar. Most clinicians know and acknowledge that one has to chip away at disorders more often than not, a little bit at a time.
So Philip’s point is a valid one — people in the real world probably don’t work toward complete remission as a stated goal (although it may be an unstated one). Instead, most real-world practice focuses on helping people reduce their overall depressive symptoms, and find better strategies for coping with life and the remaining symptoms.
While researchers need to set a line in the sand to measure success, we shouldn’t allow that sort of line be a marker for our own personal success in treatment and therapy.