Download Treatment-Resistant Depression Case 1

Treatment-Resistant Depression Case 1: Level 1
Jane is a 29 yo female who presents to your clinic stating she feels tired and
down for over 6 wks. Her PHQ-2 is positive for both questions and her PHQ-9
score is 16. She denies SI/HI. She is interested in treatments for depression, and
says she keeps seeing commercials for Cymbalta. She wonders if that would be a
good first choice…
1. What is the best screening tool for depression?
2. How do you make the diagnosis of depression?
3. List at least FIVE alternative diagnoses for Jane other than unipolar major
depression.
4. How would you treat Jane? Show your evidence!
1. Many instruments have been developed for depression screening. Although the
USPSTF found little evidence that one is superior, the most practical tool for the
clinical setting should be used.
Positive results on a screening test should trigger full diagnostic interviews that
use standard diagnostic criteria from the Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. (DSM-IV). Ultrashort screening instruments, such as
the Patient Health Questionnaire (PHQ)-2 may rule out, but not definitively
diagnose, depression. However, the PHQ-2, which asks two simple questions
about mood and anhedonia, has strengths. It is as effective as longer screening
instruments, such as the Beck Depression Inventory or Zung Depression Scale.
The PHQ-2 has been found to be up to 97 percent sensitive and 67 percent
specific in adults, with a 38 percent positive predictive value and 93 percent
negative predictive value. It is reported to have a 74 percent sensitivity and 75
percent specificity in adolescents. The PHQ-9 is one of the most common
instruments used for depression screening. Although it can be used on its own as
a screening test or to monitor treatment, it is increasingly administered for
confirmation of a positive PHQ-2 result. The PHQ-9 is valid, takes two to five
minutes to complete, and has demonstrated 61 percent sensitivity and 94
percent specificity for mood disorders in adults, and 89.5 percent sensitivity and
77.5 percent specificity in adolescents.
2.
3. a. Bipolar disorder
b. Substance abuse
c. OCP’s
d. Anemia
e. Hypothyroidism
f. Malignancy
g. Migraine
h. Medications/supplements
4. See attached figures for assistance and/or www.star-d.org
For initial treatment of depression, the effectiveness of antidepressant medication
is comparable between classes; therefore, selection of a particular
antidepressant should largely be based on the side effect profile of the drug, any
history of response in the patient or a family member, and cost of the medication.
Evidence regarding psychotherapy and pharmacotherapy has recently been
enhanced by results from the STAR*D (Sequenced Treatment Alternatives to
Relieve Depression) study, a seven-year randomized controlled trial (RCT) that
evaluated medication switching and augmentation in 3,671 outpatients with
unipolar depression. Citalopram (Celexa) was the initial treatment (20mg daily,
titrated to 60mg daily if needed). Three additional levels of treatment were
included, based on response. Each treatment level was sustained for at least 12
weeks (if the drug was tolerated) before response was determined.
The STAR*D trial found that patients who received CBT after failing to respond to
citalopram (with or without continued citalopram) had similar rates of response
(i.e., at least 50% improvements in symptoms compared with baseline) and
remission (i.e., resolution of symptoms) as those who received other medication
regimens. Patients who received CBT alone (rather than in conjunction with
citalopram) achieved remission less rapidly, but they also had fewer adverse
effects than those who were switched to other medications.
A systematic review identified 16 RCTs of treatment resistant depression, all of
which were considered too small to detect an important clinical response. (Br J
Psychiatry 2002)
The STAR*D trial significantly expanded the evidence base for pharmacotherapy
of treatment-resistant unipolar major depression. Remission rates after the first
level of treatment were 37%; after the second level, 31%; after the third level, 14
percent; and after the fourth level, 13 percent. The cumulative remission rate was
67%. In general, patients who required more treatment steps had higher relapse
rates. Ultimately, fewer than one half of patients achieved sustained remission,
even after all four treatment levels.
There were significant differences between only three treatment strategies tested
in the STAR*D trial. Augmentation of citalopram with bupropion resulted in
slightly improved response rates and fewer adverse effects compared with
buspirone (Buspar), but no difference in remission rates. Augmentation of the
level 2 treatment with T3 resulted in fewer adverse effects than augmentation
with lithium, but there was no difference in effectiveness. Venlafaxine plus
mirtazapine resulted in slightly improved response rates and fewer adverse
effects compared with tranylcypromine (Parnate). Beyond these findings, the
STAR*D trial did not find that any of the studied treatments are better than
another. Other evidence suggests that augmentation of second-generation
antidepressants or TCAs with pindolol, lithium, or methylphenidate (Ritalin) is not
effective for treatment resistant depression.