Little guidance provided for second-step antidepressant selection
The most recent findings from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial provided little help regarding which medication to prescribe if an initial SSRI trial failed to result in remission of depressive symptoms. Patients who did not show remission after a Celexa (citalopram) trial were assigned to receive Wellbutrin (bupropion), Zoloft (sertraline), or Effexor (venlafaxine). Very few patient characteristics or firststep treatment features were reliably linked to differential response to any of the medications. Patients with comorbid generalized anxiety, OCD, panic disorder, PTSD, or social phobia were all less likely (sometimes to a statistically significant extent) to remit in the second step regardless of the specific medication they received. Anxious features correlated with lower remission rates across all medications. Effexor was associated with a lower chance of remission among patients with a comorbid substance abuse disorder, but given the large number of statistical tests run by the researchers, this could be a chance finding. Unsurprisingly, patients who could not tolerate Celexa in the first step were less likely to tolerate Zoloft (another SSRI) in the second step, compared to Wellbutrin or Effexor (Rush AJ et al., Arch Gen Psychiatry. 2008;65:870-881).
TCPR’s Take: In the second step of treatment, remission rates were relatively low across all medications, ranging from 18%-27% depending on the depression measure. These findings provide little helpful information for prescribers regarding medication selection for depression that is not completely responsive to first-step treatment. The January 2007 issue of TCPR offers additional advice regarding treatment-resistant depression.
SIDE EFFECT MANAGEMENT
Viagra reduces SSRI-induced sexual side effects in women
Sildefanil (Viagra) has been shown helpful in treating antidepressant-induced sexual dysfunction (AISD) in men, but no controlled trials had tested its effectiveness in women. In this trial, 98 women with SSRI associated sexual dysfunction were randomly assigned to either sildefanil or placebo; all participants continued their SSRI, and their sexual functioning was assessed at multiple times. The women were encouraged to use the medication prior to attempted sex at least twice per week. After 8 weeks, women taking Viagra had a significant benefit over those taking placebo on the primary outcome variable (Clinical Global Impression), as well as some secondary outcome variables including ability to orgasm, orgasm enjoyment, and sexual enjoyment. Clinically, 73% of women taking placebo compared with 28% of women taking Viagra reported no improvement with treatment. Viagra showed no statistically significant benefit over placebo on lubrication, desire, sexual arousal, or sex-related pain. Side effects included those typically seen with Viagra, including headache, flushing, and dyspepsia. (Nurnberg HG et al., JAMA 2008;300:395-404).
TCPR’s Take: These results are surprisingly encouraging. One of the most common sexual complaints among women on SSRIs is orgasm delay and decreased orgasm enjoyment, and Viagra appears to help significantly with both these problems. But recall that there are other ways to treat antidepressant-induced sexual dysfunction, such as switching to bupropion, taking weekend SSRI holidays, and switching to psychotherapy.
Psychiatrists providing less psychotherapy
In a nationally representative sample of office-based psychiatrists, the percentage of patient visits involving at least 30 minutes of psychotherapy dropped from 44% in 1996-1997 to 29% in 2004-2005. The percentage of psychiatrists who provided psychotherapy at every patient visit decreased over the same time-frame from 19% to 11%. Patients on Medicaid and patients who saw psychiatrists working in group practices or HMO settings were significantly less likely to receive psychotherapy from a psychiatrist, while self-pay patients and patients in the Northeast were more likely to receive such treatment. Through a series of analyses, the authors concluded that changes in payment source and the prescription of medications were the variables that most likely explain the decrease in psychotherapy provided over time (Mojtabai R, Olfson M, Arch Gen Psychiatry. 2008;65:962-970).
TCPR’s Take: It comes as no great surprise that psychiatrists are spending less of their time doing therapy, and more of their time prescribing medications. The authors speculate that this trend reflects both the increase in medication options and reimbursement policies that give a financial incentive to prescribe. Whether this is a “good” or “bad” trend is a matter of personal judgment. Presumably, patients’ therapy needs are being met by psychologists, social workers, and clinical nurse specialists, although the study did not provide data relevant to this hypothesis. The real question is whether integrated treatment (in which a single clinician prescribes meds and does therapy) is any more effective than the more common split treatment model. We plan to review this literature in a future issue.