We read “Personalizing depression treatment: 2 clinical tools” (Current Psychiatry , March 2012, p. 26-33; http://bit.ly/1nZQCXY) with interest. With lack of response or partial response to major depressive disorder (MDD) treatment, the authors’ reminder to not assume treatment resistance without systematic review of the patient’s clinical status—using the SAFER Interview—and adequacy of medication trials—using the Antidepressant Treatment Response Questionnaire (ATRQ)—is well taken.
The authors noted that the ATRQ considers only pharmacotherapy and electroconvulsive therapy (ECT), and that comprehensive assessment of treatment-resistant depression (TRD) requires asking about depression-specific, evidence-based psychotherapies. We would add that assessment should consider transcranial magnetic stimulation (TMS), which is FDA-approved for TRD and is included in the American Psychiatric Association’s treatment guidelines for MDD. The U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality characterizes TMS as having “high strength of evidence” for efficacy from well-controlled randomized controlled trials.Transcranial magnetic stimulation for major depressive disorder,” noted “The disappointing remission rates (approximately 25% to 30%) achieved in both the first and second phases of STAR*D [Sequenced Treatment Alternatives to Relieve Depression], coupled with the substantial drop off in both the subsequent chances of remission and attenuated durability of effect, argue for an earlier consideration of SGA [second-generation antipsychotics] augmentation or TMS.”Is psychiatry ripe for creative destruction?” From the Editor, Current Psychiatry , April 2012, p. 20-21; http://bit.ly/KsXAE3), psychiatrists make diagnoses by speaking with and listening to their patients, the same way we have done for decades.
Dr. Nasrallah writes, “Numerous lab data have been developed for psychiatric disorders, but extensive heterogeneity has prevented diagnostic or commercial use of those tests…” This is another way of saying that these tests essentially are useless for the practicing clinician. Diagnosis aside, any clinically based psychiatrist knows that our medications work unpredictably and inconsistently, practical psychopharmacology is a matter of trial and error, and the “gold standard” of current knowledge, the randomized placebo-controlled study, has limited applications when treating an individual patient. The sort of “creative destruction” that Dr. Nasrallah writes about cannot correct the shortcomings of current psychiatric practice.
It is wishful thinking that giving the specialty a new name or pretending to have knowledge we do not possess would “lead to a quantum leap toward a brilliant future anchored in cutting-edge neuroscience.” Until new, clinically relevant knowledge is acquired, the call for creative destruction is premature.
Boris Vatel, MD
Lecturer, Department of Psychology
University of Evansville
Evansville, IN