Treating depression: One size does not fit all

By | June 14, 2013

Nearly 15 million U.S. adults suffer from clinical depression. Treating them is currently a process of trial and error.

“It's always been a combination of physician preference, patient preference and… who you actually choose to see for your depression,” Dr. Helen Mayberg, a neurologist at Emory University School of Medicine, said. “If you choose to go see a psychologist, psychologists do therapy. If you go to your family doctor… the likelihood is that you'll be prescribed a medication.”

With fewer than 40 percent of patients achieving success with their initial treatment for depression, the majority have to wait to see if additional therapies are effective.

“It's a serious illness,” Mayberg said. “There are consequences to going another six weeks, another eight weeks, another 12 weeks on a treatment that is unlikely to work.”

Now, Mayberg and a team of researchers may have discovered a way to reduce the guesswork involved with treating clinical depression. Their study, published online in JAMA Psychiatry, suggests the solution is locked in a portion of the brain called the anterior insula.

PET scans revealed that patients who benefitted from escitalopram (an antidepressant also known by the brand name Lexapro) had different activity levels in the anterior insula than patients who responded well to “talk therapy.”

“The patients who did the best on escitalopram have high insula activity (compared to other parts of the brain),” Callie McGrath, an Emory graduate student and lead author of the study, said. “And the patients who do the best on cognitive behavioral therapy have low insula activity.”

The researchers believe they've found the first reliable indicator to guide doctors in their selection of initial treatments for clinical depression. This has the potential to spare many patients from the prolonged suffering and uncertainty associated with current trial and error methods.

“It's a very discouraging process,” said Edi Guyton, who leads local support programs with the National Alliance on Mental Illness (NAMI). “It's long. You begin to feel hopeless.”

Guyton said she struggled with treatment-resistant depression for most of her life until she was able to bring it under control through deep brain stimulation (DBS), an experimental therapy developed by Dr. Mayberg. Guyton said she hopes Mayberg's separate study on the relationship between brain activity and treatment outcomes will lead to more research that takes the hit and miss factor out of helping people with depression.

“That would be wonderful, just knowing what medicine,” Guyton said. “If you were pretty sure, even 80 percent sure, that this is gonna work for me, I think it would make all the difference in the world.”

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