Improving the Care of Patients Who Have Treatment-Resistant Depression: The Promise of the PCORnet Mood Network

Abstract

See article by Zhou et al I n this issue of JCP, Zhou and colleagues 1 review and integrate placebo-controlled efficacy trials of medications for treatment-resistant depression (TRD) to compare efficacy in a meta-analysis. They conclude that, among 11 augmentation options for TRD, aripiprazole and quetiapine have the most robust evidence for efficacy, with the caveats that these treatments carry substantial risks of adverse events and no long-term data are available. In the absence of direct comparisons, this exercise highlights the formidable challenges that clinicians face when making decisions. While Zhou and colleagues 1 provide an excellent analysis of the available data, we will argue that these findings are of limited use for most people receiving and providing care for TRD. As stated by Tricoci and colleagues in commenting on guidelines in cardiology, "the current system generating research is inadequate to satisfy the information needs of caregivers and patients in determining benefits and risks of drugs, devices, and procedures. " 2(p837) It is not just in psychiatry that we lack evidence for most clinical decisions. We need a new research paradigm beyond meta-analyses of efficacy studies.

Treating to target in major depressive disorder: response to remission to functional recovery

“…It is hoped that results from the Patient-Centered Outcomes Research Institute (PCORI) will provide instructive insights as to the appropriate "best next steps" when an initial antidepressant is unsuccessful. 101 Instead, pharmacological treatments should be integrated with general lifestyle improvement, risk factor modification, sleep hygiene, psychoeducation, and, in some cases, manual-based psychotherapy. The body of evidence supporting aerobic/ resistance exercise has also become compelling, with a particular therapeutic offering in critical patient-reported outcomes (e.g.…”

“…Notwithstanding the availability of results from efficacy studies, and more recently meta-analyses that report on and compare between-agent efficacy in MDD, there is a paucity of “real-world” effectiveness studies in MDD as augmentation to determine the most appropriate and acceptable treatment to patients and clinicians. It is hoped that results from the Patient-Centered Outcomes Research Institute (PCORI) will provide instructive insights as to the appropriate “best next steps” when an initial antidepressant is unsuccessful 101 . Instead, pharmacological treatments should be integrated with general lifestyle improvement, risk factor modification, sleep hygiene, psychoeducation, and, in some cases, manual-based psychotherapy.…”