Tag: depression

STARD – Treatment used in the Study

NIMH Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study — All Medication Levels

The NIMH-funded Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study was conducted to determine the effectiveness of different treatments for people with major depression who have not responded to initial treatment with an antidepressant. This is the largest and longest study ever conducted to evaluate depression treatment. This page provides information about the study.

What were the treatments used in the study?

In level 1, participants were given the antidepressant citalopram (Celexa) for 12 to 14 weeks. Those who became symptom-free during this time could move on to a 12-month follow-up period during which the citalopram was continued, and patients were monitored. Those who experienced intolerable side effects or did not become symptom-free during this level could go on to level 2.

Citalopram is representative of the class of antidepressant medications known as selective serotonin reuptake inhibitors (SSRIs). It was chosen as the first treatment because it generally is not associated with troublesome withdrawal symptoms when it is stopped, is easy to administer (once a day), and has been shown to be safe for older adults and medically fragile patients. It does not appear to interact unfavorably with other medications that some participants may have been taking for other medical problems.

Level 2 was designed to help determine an appropriate next treatment step if the first step did not work. Thus, in level 2, participants had the option of switching to a different medication or adding on to their existing citalopram.

Those who joined the “switch” group were randomly assigned to either sertraline (Zoloft), bupropion-SR (Wellbutrin), or venlafaxine-XR (Effexor). These medications were chosen for comparison because they represent three different types of medications. Sertraline is an SSRI, the same class as the citalopram used in level 1. Bupropion belongs to another class of antidepressant medications that work on different neurotransmitters than SSRIs. Venlafaxine is a “dual-action” medication that works on two neurotransmitters at the same time.

Those who joined the “add-on” group were prescribed either the non-SSRI antidepressant bupropion-SR (Wellbutrin), or buspirone (BuSpar), which is not an antidepressant but enhances the action of an antidepressant medication. Participants could also switch to, or add on, cognitive psychotherapy.

As in level 1, those who became symptom-free with their level 2 treatment could continue with that treatment and entered the follow-up period. Those who did not become symptom-free, or who experienced intolerable side effects, could continue on to level 3.

In level 3, which like level 2 was designed to compare medications that are thought to work differently in the brain and produce different results, participants again had the option of either switching to a different medication or adding on to their existing medication. Those who chose to switch their medication were randomly assigned to either mirtazapine (Remeron) — a different type of antidepressant — or to nortriptyline (Aventyl or Pamelor) — a tricyclic antidepressant — for up to 14 weeks. Both work differently in the brain than the SSRIs and other medications used in levels 1 and 2.

In the level 3 add-on group, participants were randomly prescribed either lithium — a mood stabilizer commonly used to treat bipolar disorder — or triiodothyronine (T3) — a medication commonly used to treat thyroid conditions — to add to the medication they were already taking. These medications were chosen because they have been shown to boost the effectiveness of antidepressant medications.

In level 4, participants who had not become symptom-free in any of the previous levels (and therefore considered to have highly treatment-resistant depression) were taken off all other medications and randomly switched to one of two treatments — the monoamine oxidase inhibitor (MAOI) tranylcypromine (Parnate) or the combination of venlafaxine extended release (Effexor XR) with mirtazapine (Remeron). These treatments were chosen for comparison because previous research had suggested that they may be particularly effective in people who had not received sufficient benefit from other medications.

How were participant’s doses decided and how was their progress measured?

To ensure that every participant had the best chance of recovery with each treatment strategy, a systematic approach called measurement-based care was used. This method requires routine, consistent measurement of symptoms and side effects at each treatment visit with easy-to-use measurement tools. It also involves the use of a treatment manual that describes when and how to modify medication doses and dose adjustments to best tailor them for individual participants so as to minimize side effects, maximize safety, and provide the best chance of therapeutic benefit. This enabled STAR*D practitioners to provide consistent, high-quality care.

STAR*D employed easy-to-use rating tools of symptoms and side effects in a systematic and consistent way. These tools can readily be incorporated into real-world medical and psychiatric settings. Use of this measurement-based care may have caused greater than expected remission rates.

Patients were asked to self-rate their symptoms. The study demonstrated that most depressed patients can quickly and easily self-rate their symptoms and estimate their side effect burden in a very short time. Their doctors can rely on these self-rated tools for accurate and useful information to make informed judgments about treatment. The patients can also use these tools to help manage their illness at home in much the same way that hypertensive patients can measure their own blood pressure.

STARD – Results of the Study on Depression Other Treatments

NIMH Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study — All Medication Levels

The NIMH-funded Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study was conducted to determine the effectiveness of different treatments for people with major depression who have not responded to initial treatment with an antidepressant. This is the largest and longest study ever conducted to evaluate depression treatment.

What were the results?

In most clinical trials of treatment for depression, the measure of success (outcome) is called “response” to treatment, which means that the person’s symptoms have decreased to at least half of what they were at the start of the trial. In STAR*D, the outcome measure was a “remission” of depressive symptoms—becoming symptom-free. This outcome was selected because people who reach this goal generally function better socially and at work, and have a better chance of staying well than do people who only achieve a response but not a remission.

In level 1, about one-third of the participants reached remission and about 10-15 percent more responded, but did not reach remission. Still, these are considered good results because study participants had high rates of chronic or recurrent depression and other psychiatric medical problems.

It took an average of six weeks of treatment for participants to improve enough to reach a response and nearly seven weeks of treatment for them to achieve a remission of depressive symptoms. In addition, participants visited their care providers an average of five to six times. Participants who achieved remission stayed on the treatment for an average of 12 weeks before going on to a 12-month follow-up period.

In the level 2 switch group, about 25 percent of participants became symptom-free. All three of the switch medications performed about the same and were equally safe and well-tolerated. In the add-on group, about one-third of participants became symptom-free. Those who added bupropion experienced less troublesome side effects and slightly more reduction of symptoms than those who added buspirone.

In levels 2 and 3 where participants were allowed to either add-on or switch medications, most participants found only one or the other treatment strategies acceptable. Because most participants did not agree to be randomly assigned to one or the other treatment strategy, the findings of the add-on and switch approaches cannot be compared. It is likely, however, that people being treated in the real world also tend to limit their treatment preferences to switching or adding on medications. In addition, the people in the switch and add-on groups were a little different. The group who chose and were assigned to a switch medication had more problematic side effects while taking the preceding medication (citalopram) than the group who chose and were assigned to an add-on medication.

Level 2 also included cognitive psychotherapy as a switch or add-on treatment. Results for the psychotherapy treatment are not yet available.

In the level 3 switch group, 12 to 20 percent of participants became symptom-free, and the two medications used fared about equally well, suggesting no clear advantage for either medication in terms of remission rates or side effects. In the add-on group, about 20 percent of participants became symptom-free, with little difference between the two treatments. However, the T3 treatment was associated with fewer troublesome side effects than lithium.

In level 4, seven to 10 percent of participants became symptom-free, with no statistically significant differences between the medications in terms of remission, response rates or side effect burden. However, those taking the venlafaxine-XR/mirtazapine combination experienced more of a reduction in depressive symptoms than those taking the tranylcypromine. Also, those who were treated with tranylcypromine were more likely to discontinue the treatment citing side effects as the reason. It is also possible that the dietary restrictions associated with taking an MAOI could have limited its acceptability as a treatment.

In conclusion, about half of participants in the STAR*D study became symptom-free after two treatment levels. Over the course of all four treatment levels, almost 70 percent of those who did not withdraw from the study became symptom-free. However, the rate at which participants withdrew from the trial was meaningful and rose with each level—21 percent withdrew after level 1, 30 percent withdrew after level 2 and 42 percent withdrew after level 3.

What lessons are learned from the results?

For the first time, doctors and people with depression now have extensive data on antidepressant treatments from a federally funded, large-scale, long-term study directly comparing treatment strategies.

Results from level 2 indicate that if a first treatment with one SSRI fails, about one in four people who choose to switch to another medication will get better, regardless of whether the second medication is another SSRI or a medication of a different class. And if patients choose to add a new medication to the existing SSRI, about one in three people will get better. It appears to make some—but not much—difference if the second medication is an antidepressant from a different class(e.g. bupropion) or if it is a medication that is meant to enhance the SSRI (e.g. buspirone). Because the switch group and the add-on group cannot be directly compared to each other, it is not known whether patients are more likely to get better by switching medications or by adding another medication.

Results from level 3 apply to those who do not get better after two medication treatment steps. By switching to a different antidepressant medication, about one in seven people will get better. By adding a new medication to the existing one, about one in five people will get better. Level 3 results also tell us that adding T3 may have some advantages over adding lithium for patients who have tried two other treatments without success.

Finally, for patients with the most treatment-resistant depression, level 4 results suggest that tranylcypromine is limited in its tolerability and that up to 10 percent may benefit from the combination of venlafaxine-XR/mirtazapine.

An overall analysis of the STAR*D results indicates that patients with difficult-to-treat depression can get well after trying several treatment strategies, but the odds of beating the depression diminish with every additional treatment strategy needed. In addition, those who become symptom-free have a better chance of remaining well than those who experience only symptom improvement. And those who need to undergo several treatment steps before they become symptom-free are more likely to relapse during the follow-up period. Those who required more treatment levels tended to have more severe depressive symptoms and more co-existing psychiatric and general medical problems at the beginning of the study than those who became well after just one treatment level.

These results underscore both the need for a better understanding of how different people respond to different depression treatments, and the challenges in finding broadly effective, short- and long-term depression treatments. Future research may help identify which treatments work for which patients.

What do the STAR*D results mean to people with MDD and their doctors?

The results reiterate the need for high-quality care and attention to the individual needs of patients. Doctors should provide medication at optimal doses, be aware of and offer treatment choices, and maintain diligent monitoring of patients both during treatment and after they become symptom-free so as to avoid relapse.

Like other medical illnesses, depression affects different people in different ways, but a wide range of effective treatments exist. People with depression should not give up if their initial treatment attempts do not result in full benefits. They should continue to work with their doctors to find the best treatment strategy.

In addition, patience is required. While some people may experience benefits in the first six weeks of a treatment strategy, full benefits may not be realized until 10 or 12 weeks have passed. During this time, doctors should work with their patients to adjust dosages so as to find an optimal level, and avoid stopping a treatment prematurely.

STARD Study – What were the goals of trial?

NIMH Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study — All Medication Levels

The NIMH-funded Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study was conducted to determine the effectiveness of different treatments for people with major depression who have not responded to initial treatment with an antidepressant. This is the largest and longest study ever conducted to evaluate depression treatment. This page provides information about the study.

What were the goals of the STAR*D trial?

The overall goal of the STAR*D trial was to assess the effectiveness of depression treatments in patients diagnosed with major depressive disorder, in both primary and specialty care settings. It is the largest and longest study ever conducted to evaluate depression treatment.

Each of the four levels of the study tested a different medication or medication combination. The primary goal of each level was to determine if the treatment used during that level could adequately treat participants’ major depressive disorder (MDD). Those who did not become symptom-free could proceed to the next level of treatment.

The design of the STAR*D study reflects what is done in clinical practice because it allowed study participants to choose certain treatment strategies most acceptable to them and limited the randomization of each participant only to his/her range of acceptable treatment strategies. No prior studies have evaluated the different treatment strategies in broadly defined participant groups treated in diverse care settings.

Who participated in the study?

Over a seven-year period, the study enrolled 4,041 outpatients, ages 18-75 years, from 41 clinical sites around the country, which included both specialty care settings and primary medical care settings. Participants represented a broad range of ethnic and socioeconomic groups. All participants were diagnosed with MDD and were already seeking care at one of these sites. No media advertisements were used to recruit participants. Instead, they were referred to the trial by their doctors.

So that results could be generalized to a broad group of real-world patients, most adults with MDD were eligible. People were not eligible for the study if they had not tolerated or did not get well with one or more of the treatments that were part of the first two STAR*D treatment steps, or if a STAR*D treatment could not be safely used because of another medical condition or because they were taking certain other medications. In addition, people with substance abuse disorders that required detoxification, anorexia or bulimia, or obsessive compulsive disorder were not eligible for the study because they required treatments that were not part of STAR*D.

Of the initial 4,041 participants, 1,165 were excluded because they either did not meet the study requirements of having “at least moderate” depression (based on a rating scale used in the study) or they chose not to participate. Thus, 2,876 “evaluable” people were included in level 1 results. Level 2 results include 1,439 people who did not become symptom-free in level 1 and chose to continue. Level 3 results include 377 people, and Level 4 results include 142 people.

How Do Leaders Deal With Disruption and Changes in Life?

President Kennedy wrote: “Change is the law of life and those who look only to the past or present are sure to miss the future.”

Change simply means that something is different than it was a minute, a day, a week, a month, a year or a decade or more ago. Some trigger has modified the details of your life, the organization you work for, even global economic conditions.

Change can be caused by evolving external forces, such as the rise of ISIS. Most people did nothing to start this phase of terror perpetrated on the world. But that doesn’t mean they can avoid its ramifications.

And then some change is fostered internally, by the change in the way you see your life going, by new perspectives on your employment, education, relationships, and your health.

Change is disruptive and can even be turbulent — especially when it hits close to home and plays with our emotions. But then leadership today is all about managing disruption. And disruption is an hourly occurrence. Leaders are people who don’t just learn to live with or manage change — they actually create change and help others successfully navigate it.

Listen carefully to catch the change behind the change. Change can be tricky and misleading. Be careful not to make a superficial translation of some trend only to be led down some dead end. Not all change is what it seems on the surface.

If you don’t truly get under the change and analyze it before you react to it, you may miss something — like the critical time to quit your job and move on. You are not the only person in the world affected by change. You may be stuck in a trap where you think that you caused the change in your life and that it is harmful to you alone.

Targeted actions for managing Change for Leaders like CEO’s

Targeting pockets of opportunity: CEOs should focus on a few well chosen initiatives, primarily in their existing markets, to stimulate organic growth.

Concentrating on the customer – CEOs are creating new ways to demand and foster customer loyalty. Few could be capitalizing on digital marketing platforms and involving customers in product/service development. But does not mean they have a open budget. They need to cut down cost of R&D and take care of innovation.

Improving operational effectiveness – CEOs should be balancing efficiency with agility.

Are you having Self Control over yourself?

Self control is defined by the experts as the impulse control or the ability to delay displaying gratification and controlling emotions. According to the prominent university research, if the person has a better self control, then it leads to better health and prosperity further discouraging crime and substance abuse. It is a vital ingredient in day to day behavior for achieving desired goals and remove all the harmful impulses or emotions.

Questions To Ask Yourself

Do you want to know where you stand towards the self control aspect and how do you think it is going to impact your life? Try answering these questions and know how control you have over yourself?

Are you Emotionally Stable – Do you have generally stable and peaceful mood which does not change drastically within span of hours or minutes, until and unless there is any reason/event for such change?

Are you feeling stable with respect to Self-Image & Life Goals – Do you know who you are and where you are going in your life? Are you certain about your position, standing and journey in life?

Do you have a stable personal relationship – Are you in a stable relationship and you are living peacefully in that relation?

Do you exhibit caution while taking important decisions in your life? – Do you think carefully before saying something or taking some action?

Do you follow genuineness in your day to day life? – Do you have theatrical or attention-seeking ways of speaking and acting?

Do you maintain Chasity in your like and avoid having casual sex (“one night stands”)?

Internet Use And Depression

Excessive Internet Use Causes Depression and Related complications

No one can deny that the Internet is most influential force on society in the entire human history. We never had such an unprecedented access to news, knowledge, and entertainment from cultures all around the world, before the advent of Internet. Although this treasure of information is huge and precious, this wealth has led to something called digital information overload. The human minds cannot handle such kind of constant influx of information without making changes.

Internet addiction is recognized as a psychological disorder which can make people spend too much time on a computer.  This affects their health, job, relationships or finances. Whether it is depression which causes people to turn to the Internet for social fulfilment, or whether excessive use of the Internet can make people depressed – this is subject to research and discussion.

A new research study by psychologists at Leeds University, England postulated that people who spend 10 hours or more a day online are more likely to show signs of depression.

Over-engaging in websites that replaces the normal social interaction like Facebook might be linked to psychological disorders like depression and addiction. Moderate to severe depression is likely to happen among people who are addicted to the Internet.

Recognizing Depression due to surfing online

People who spend high amounts of time surfing online does not realize the impact of lack of social interactions. Slowly the depression symptoms start piling on them. Know these early signs of depression from the National Institute of Mental Health:

  1. Difficulty concentrating and making decisions
  2. Decreased energy and fatigue
  3. Feelings of guilt, worthlessness or helplessness
  4. Feelings of hopelessness or pessimism
  5. Insomnia, early-morning wakefulness or excessive sleeping
  6. Irritability and restlessness
  7. Loss of interest in activities or hobbies once found pleasurable
  8. Overeating or appetite loss
  9. Persistent aches or pains, headaches, cramps or digestive problems
  10. Persistent sad, anxious or “empty” feelings
  11. Thoughts of suicide or suicide attempts

Ketamine for Bipolar Disorder

Ketamine Helps Patients With Bipolar Disorder – All you need to know about Ketamines?

Ketamine is an anesthetic and if it is used in higher doses it can also relieve depression within hours when taken intravenously. According to a research by Morteza Jafarinia and colleagues in the Journal of Affective Disorders, oral ketamine can help in treatment of mild to moderate depression in people with severe pain.

In this study the scientists compared 150mg daily doses of oral ketamine to 150mg daily doses of the anti-inflammatory pain reliever Diclofenac over 6 weeks. The subjects were interviewed after week 3 and week 6 and the ketamine group reported fewer symptoms of depression than the Diclofenac group.

This effect of Ketamine is the result of the blockade of a particular receptor for the neurotransmitter glutamate (the NMDA glutamate receptor). Researchers originally thought that the NMDA blockade was linked to ketamine’s antidepressant effects, but this appears not to be the case.

How Ketamines works?

Ketamine are strange substance and they works in a completely different way from other medicines you have ever taken for depression, bipolar, PTSD, or anxiety. Most of the medicines work by manipulating the quantity of certain neurotransmitters in your brain, which can have miserable side effects. Ketamine works differently since it briefly blocks a certain type of receptor in the brain from being triggered. Ketamine is not a one-time, permanent cure but it has the potential for lasting relief.

In general, a series of multiple injections gives longer, faster and lasting relief than a single infusion, and younger patients tend to get longer relief than older ones. For patients who relapse, getting additional infusions can often restore the relief.

Further use of Ketamines

According to a study, adding two more existing drugs to Ketamines, prolongs the effect of Ketamine which otherwise has very short lived effects. They after the addition effectively reduce symptoms of depression and suicide in patients with bipolar depression.

Walking is the New Found Therapy

Walking can be your natural medicine for happiness as it helps release happy hormone called endorphin.

Walking not only helps you burn calories but is also considered the most effective anti-depressant. Almost 97 percent walkers revealed that it helped them improve their mental health and emotional well-being. The survey also revealed that walking helps control stress among people across age groups. While 42% of the elderly feel that walking helps beat stress, 50% of the millennials experience reduction of stress and hypertension, post walking, it added.

This is the highest for millennials. Interestingly, over 40% of the respondents are motivated to walk because of interesting walking apps and gadgets that help them track their health.

Usage of gadgets is more prominent among millennials. The Survey further said those who don’t walk regularly are more prone to depression nearly 15% of non-walkers admitted to be suffering from depression and high stress levels.

According to the survey, walking gives millennials time for self-introspection, while it gives 21% elderly the feeling of self-reliance. But there is a flip side as well. About 43% are unable to walk as long daily commute leaves them with no time for walking, 29% get bored while walking and believe that walking will not have a positive impact on their personality, 21% lack company to walk, and 21% are unaware of the benefits of walking on their mental health.

Video Games Relieve Depression

Can Video Games Help Relieve the Symptoms of Depression?

According to research and multiple studies conducted across the western world, there is promising results shown in the treatment of depression with a video game interface which fights with underlying cognitive issues associated with depression. They just do not manage the symptoms only.

Different studies on Depression and Video Games

There were many studies conducted on the implications of video games on depression. The first study enrolled older adults diagnosed with late-life depression into a treatment trial where they were randomized to receive either a mobile, tablet-based treatment technology developed by Akili Interactive Labs called Project: EVO or an in-person therapy technique known as problem-solving therapy (PST).

Project: EVO was an app running on tablets or mobile phone and was designed to improve focus and attention at a basic neurological level. The people who were using the app from Project: EVO demonstrated specific cognitive benefits compared to the behavioral therapy, and saw similar improvements in mood and self-reported function.

Joaquin A. Anguera, from University of California, San Francisco (UCSF), who is a researcher in neurology and psychiatry, performed this study and intervention manufactured by Akili Interactive Labs, Boston was used.  The study is funded by National Institute of Mental Health.

As per another research study going on at the University of California, Davis – using video games and brain training applications can help treat depression. The study found that not only can video games potentially treat depression, but when participants are reminded to play games, they are more likely to play more often and increase time playing.

An App, a Video Game, and a Placebo for Depression

A larger trial was conducted with more than 600 participants having mild or moderate depression. These participants assessed the value of different video games in the treatment of depression. One group played Project: EVO, second used an app called iPST, while the third used placebo control who used an app called Health Tips, suggesting health suggestions.

For mild depression, all three groups’ experienced similar improvements, while people who had more than mild depression saw greater improvements with iPST and Project: EVO than with the placebo app.

Video game has nothing to do with mental health, but it can help fixing brain function in people who suffer from this particular flavor of depression.

Video Games Relieve Depression

Video Games has the power to relieve depression

Researchers have found promising results for treating depression with a video game interface that targets underlying cognitive issues associated with depression rather than just managing the symptoms.

According to Dr. Patricia Areán, a UW Medicine researcher in psychiatry and behavioral sciences, the findings are both intriguing and promising.  The first study enrolled older adults diagnosed with late-life depression into a treatment trial where they were randomized to receive either a mobile, tablet-based treatment technology developed by Akili Interactive Labs called Project: EVO or an in-person therapy technique known as problem-solving therapy (PST).

Project:EVO

The Project: EVO runs on phones and tablets and is designed to improve focus and attention at a basic neurological level. The results showed that the group using Project: EVO demonstrated specific cognitive benefits (such as attention) compared to the behavioral therapy, and saw similar improvements in mood and self-reported function. The studies were funded by the National Institute of Mental Health.

Another research on Video Games effects on Depression

Researchers at the University of California Davis are using video games and brain training applications to treat depression. The study found that not only can video games potentially treat depression, but when participants are reminded to play games, they are more likely to play more often and increase time playing, which may help patients gain further benefit from the treatment, though the researchers did not measure that.

The study used six, three-minute specifically designed video games played by 160 student participants with an average age of 21. The study showed in most cases playing a game helped participants feel they had some control over their depression. The games were an adaptation of neurophysiological training tasks shown to improve cognitive control in people with depression.

The messages used to remind participants to play the video games targeted depression as either internal from a chemical imbalance or hereditary, or external from environmental and lifestyle factors. The reminder messages had differences in approach but all concluded with inspirational notes to encourage participants to play the game.