Improving Depression Treatment Outcomes Requires More Precise Definitions

Those five elusive “Rs” of treatment—Response, Remission, Relapse, Recovery, and Recurrence—are benchmark treatment outcomes, yet their definitions remain uncertain and often misunderstood when clinicians try to apply them in the treatment of major depression.

That lack of precisely defined and clearly communicated treatment goals contributes to the high percentage of patients who receive inadequate treatment, said Martin Keller, M.D., a professor of psychiatry and human behavior at Brown University. In a “special communication” in the June 18 Journal of the American Medical Association, Keller explored current understandings of the optimal goal for depression treatment and what needs to occur to improve outcomes.

“I think the proportion of patients who need to be treated for depression and are not given the appropriate treatment for a sufficient time at a sufficient dose is still too high,” Keller told Psychiatric News.

Another report in that same issue of JAMA indicates that less than half of those who pursued treatment for depression within the 12 months prior to the survey received minimally adequate treatment.

While the vast majority of clinical trials involving antidepressant medications, as well as psychotherapy interventions, have focused on “response,” the definition of response has varied, Keller said. It is typically defined as more than a 50 percent decrease from baseline scores on a standardized scale, Keller wrote, but even a 50 percent reduction could leave a patient with significant symptoms.

“The important thing here,” he said, “is that we have to strive to meet remission, not response, as the goal of treatment.”

Wellness, Keller emphasized, must be determined by “evaluating a combination of three key domains: symptoms, functional status, and pathophysiological changes.” But he continued, “At this point we are reliant on purely clinical factors as the outcome variables and what I would call remission—based on a state of no or very minimal symptoms and a return to normal functional status—is really what we should be aiming for in patients with depression.”

Keller noted that studies have strongly indicated that patients achieving remission have a much better prognosis in the long term. But remission should be defined as a set endpoint on a depression scale, such as a score of 7 or less on the Hamilton 17-Item Depression Rating Scale or a score of 10 or less on the Montgomery-Asberg Depression Rating Scale. These scores have been shown to differentiate reliably those who do not have depression from those who have even mild depression.

Psychiatrists, Keller noted, know this. “None of what I am saying is earth shattering. But in the primary care world [where the vast majority of patients with depression are treated], these scales and specific scores are largely lost.”

He continued, “There is a great deal of effort ongoing to help primary care physicians be more aware of and identify patients with depression.” But efforts that reinforce the variety of available treatments and that help primary care physicians understand the importance of treatment outcomes are still needed.

“The outcome goals, unlike those for most other medical illnesses, are not based on laboratory values or diagnostic procedures, so in making the original diagnosis, you have to be sensitive to that and appreciate the difficulty of gauging improvement,” he said.

“We have a variety of treatments that are efficacious, safe, and tolerable,” Keller concluded. “They simply need to be used in a more rigorous and thorough way.”

An abstract of Keller’s “special communication” in the June 18 JAMA is posted on the Web at http://jama.ama-assn.org/cgi/content/abstract/289/23/3152. ▪

JAMA 2003 289 3152