1. Preventing Learned Helplessness In Depression Treatment Guideline Users Douglas E. Jorenby, Ph.D. Associate Professor 28 September 2005

2. Disclosures No commercial support Salary support from NIH, DOM, UWMF, and RWJF

3. Learning Objectives Be able to select effective treatments congruent with the Depression Treatment Guideline Access behavioral treatment with maximum efficiency

4. 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

5. Significant History Previous depressive episode + response to multi-drug pharmacotherapy + response to psychotherapy Self-initiated bibliotherapy

6. “I read that antidepressants are no better than placebos.”

7. 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.”

8. 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

9. Methodological Critique No gradient of effect from “moderate” (14-18) to “severe” (19- 22) to “very severe” (>22) Lack of true blinding in placebo- controlled studies Publication bias Moncrieff J, Kirsch I. Efficacy of antidepressants in adults. BMJ 2005;331:155-9

10. 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.

11. 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data submitted to the US FDA for the six most widely prescribed antidepressants approved 1987-1999 Published and unpublished results were utilized Kirsch I, et al.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.

12. Mean Improvement Observed Kirsch I, et al. Prevention & Treatment 2002;5:1-12. # of TrialsNDrugPlaceboProportion Fluoxetine 51,1328.307.34.89 Paroxetine 121,2899.886.67.68 Sertraline 37799.967.93.80 Venlafaxine 61,14811.548.38.73 Nefazodone 81,42810.718.87.83 Citalopram 41,1689.697.71.80

13. Balanced Placebo Solution? Get Told DrugNo Drug DrugDrug + Placebo Placebo No DrugDrugBaseline

14. “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.

15. 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

16. Admiral Hopper Was Wrong Prior Authorization through Behavioral Health Consultation Service 1-800-683-2300 OR 282-8960 Two-stage process

17. 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

18. 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

19. 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