 Aim for Full Remission
Treatment of depression with venlafaxine
In treating depression, psychiatrists must aim for "full remission" as the measure of success, and not settle for mere treatment response or "incomplete remission." "With proper treatment, the vast majority of patients can indeed obtain full remission," said Dr. Michael Thase, professor of psychiatry at the University of Pittsburgh School of Medicine.
Addressing Filipino psychiatrists during a symposium on Achieving Remission: Comparing Antidepressant Treatments organized by Wyeth Philippines October 31 last year, Dr. Thase said that this new paradigm prompts psychiatrists to consider "incomplete remission as nothing more than a station on the way to full remission."
While acknowledging that remission in depression is difficult to quantify unlike in the treatment of cancer, Dr. Thase said "we can describe the syndrome or burden both in terms of symptoms and functional impairment and apply similar standards in terms of relief of symptoms."
"When you have a level of symptom improvement like that of someone who has never been depressed, you almost have restoration of functional capacity," he explained.
He stressed that complete remission should be the goal because depression-the most prominent underlying risk factor for suicide-remains undertreated. Only half of patients get treatment and only one in five is treated adequately.
Dr. Thase said adequate treatment may be observed if there is resolution of emotional and physical symptoms as well as restoration of the patient's full capacity of functioning. This would also include normalization of the patient's lifestyle, capacity to work, interest in hobbies, and social relationships.
When treatment is inadequate and remission is not sustained, patients run a greater risk of relapse, suffer longer chronic depressive episodes, and continue to have impaired daily function. The risk of suicide is also higher, as well as mortality and morbidity associated with stroke, DM, myocardial infarction, and congestive heart failure.
Citing a study by Paykel, Dr. Thase said three of four patients who do not achieve sustained remission would have a relapse within seven months to one year. In contrast, only one of four patients who achieve complete remission-a period of nine months to one year during which the patient experiences no depression symptoms and is able to function normally-is likely to have a relapse.
This is why, he said, optimal efficacy should be the top consideration in the selection of a first-line antideppresant. Unfortunately, however, that is not the case. The main considerations have always been tolerability, safety, dosing, and cost, he said, adding "efficacy is not a differential consideration."
"Individual patients respond dramatically to different antidepressants and no type or class of antidepressant has stood out [over the others]," argued Dr. Thase, noting that differences, though often deemed insignificant, exist between drugs-and they are "meaningful."
"One meaningful difference is that antidepressants that simultaneously affect norepinephrine and serotonin have stronger antidepressant effects," he said.
Venlafaxine (Efexor) is a serotonin-norepinephrine reuptake inhibitor (SNRI) that increases the levels of serotonin and norepinephrine in the brain.
Dr. Thase said one evidence of venlafaxine's edge over other drugs in achieving remission rates was seen in the Comprehensive Pooled Analysis of Remission (COMPARE) metaanalysis of 32 studies from various centers around the world that involved more than 7,000 patients. He said that while the analysis confirmed that SSRIs are good antidepressants, and better than placebo as expected, venlafaxine "offered efficacy above that of the SSRIs."
An analysis of eight large randomized controlled trials involving SSRIs and venlafaxine also found that not only is depression easier to treat early in its episode, but that venlafaxine had a higher rate of remission compared with SSRIs. Also, more patients on venlafaxine reported resolution of physical, emotional, and functional symptoms. Venlafaxine had the lowest discontinuation rate (25 percent) among other antidepressants like bupropion (38 percent) or sertraline (27 percent).
Summing up, Dr. Thase gave the following tips to psychiatrists to "make their first choice of treatment count":
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Aim for remission and choose agents with proven efficacy, then use optimal dose. |
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Minimize dropout by taking into account efficacy, tolerability, and safety. |
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Prevent relapse by achieving remission for adequate duration of theraphy. |
"Venlafaxine is the only available dual reuptake inhibitor you can think of as first-line treatment," ended Dr. Thase.
Lucio Victor Jr.
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