Preventing Learned Helplessness In Depression Treatment Guideline Users

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data submitted to the US FDA for the six most widely prescribed antidepressants approved 1987-1999 • Published and unpublished results were utilized Kirsch I, et al.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

13. Balanced Placebo Solution?

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