Some patients who have failed three courses of drug treatment for depression may still derive benefit from a fourth set of drugs, according to the largest study of treatment-resistant depression, the Sequenced Treatment Alternatives to Relieve Depression or STAR*D trial.
A total of 4,041 depressed patients were originally enrolled in the study to test the most effective treatments for their disorder. Those who failed to improve with the initial drug, citalopram, were given a second course of different drugs, then a third. Each course of drugs benefited additional patients.
Of those who failed the first three courses, 109 entered the fourth level, which compared the old, rarely used drug tranylcypromine with a combination of newer antidepressants, venlafaxine and mirtazapine.
Dr. Patrick J. McGrath of the Columbia University Medical Center and his colleagues reported in this month's American Journal of Psychiatry that the drugs produced modest and comparable benefits, with remission rates of 7% and 14% respectively.
Because of the small number of patients, the difference was not statistically significant.
Overall, the venlafaxinemirtazapine combination produced a 25% reduction in symptoms, whereas tranylcypromine produced a 6% reduction.
The study indicates that "the patient who has not responded to two or three previous treatments still has hope for a remission from his or her depression," said the journal's editor, Dr. Robert Freedman of the University of Colorado Health Sciences Center in Denver.
For patients who failed all four courses of treatment, the team said, physicians may have to consider alternative treatments such as electroconvulsive therapy or vagus nerve stimulation.