Insight into Keeping Depressed Patients in Treatment
> 8/10/2007 1:18:51 PM

Antidepressant treatment has a high chance of eventually sending depression into remission, but many patients do not have the patience to wait for "eventually." More than one-fourth of patients drop out of their treatment program, many after their very first visit. This is unfortunate, because it often takes a few weeks for the right drug to be found and for beneficial effects to manifest.

Dr. Diane Warden recently analyzed the massive STAR*D study to tease out what factors correlate with quitting treatment. She focused on the 4,041 outpatients in a citalopram (Celexa) treatment program, a group that approximately mirrored the racial composition of the general American public. In addition to noting the high 26% attrition rate by the end of the trial, attrition statistics were divided into three time periods: 34% of attrition occurred before a second visit, 59% between the second visit and week 12, and 7% after week 12.

Both immediate attrition and later attrition (anything after 2nd visit) were associated with youth and lower education level. There were two factors that differed with timing-- immediate dropouts displayed better mental functioning and later dropouts were more likely to be African American. The explanation for the two common factors can be readily intuited as a lack of understanding. Younger and less educated patients have less life experience and less of an ability to understand medical advice on the necessity of sticking with antidepressants. The early attrition of high functioning patients has an obvious logic as well; patients with relatively intact lives do not feel the desperation that keeps more devastated patients dedicated to treatment.  

The later attrition of African Americans is harder to explain. It might be best to view this finding together with two other factors that were noteworthy but did not meet the strict requirement for statistical significance. Hispanics and those using public health insurance were more likely to drop out. It is possible that some cultures have greater taboos against admitting you need help from medication. However, if socioeconomic status rather than race is the primary risk factor for attrition, then the STAR*D study, however well-orchestrated, is not the ideal place to look because it supplied participants with free antidepressants. Economic factors may have a much more obvious impact when patients must take their insurance plan and personal savings into account to decide whether to continue with treatment.

Research of this kind will give doctors practical guidelines to minimize attrition. On the basis of Dr. Warden’s work, it seems prudent to pay careful attention to young, uneducated, and minority patients. Even if the reasons behind these group differences are never discovered, just knowing who is at greatest risk allows doctors to direct additional encouragement to those groups. In addition, knowledge of the riskiest times for attrition will allow for a more effective concentration of effort. This general demographic information can be combined with pharmocogenomics, a science that uses DNA to predict individual reactions to specific drugs, to take much of the guessing out of antidepressant treatment. All of this information will help patients get through the frustrating weeks when medication has yet to make noticeable progress against depression.

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