| John
Rush, M.D., professor of psychiatry at University of Texas Southwestern,
told his convention audience about a multiyear project called
the Texas Medications Algorithm Project (TMAP). The goal of
algorithm development is to create a structured approach to
making treatment decisions, based on a combination of research
and expert opinion. Algorithms take a series of points in treatment
where treatment decisions are made and ask the right questions
(for example: "What are the best first-medication options
for this patient?" "If that first treatment does not
work, what are the best alternatives for the next step?").
For each decision point, the algorithm then spells out the best
actions.
But, of
course, algorithms are only useful if they are actually used.
TMAP will be studying the actual introduction and use of these
algorithms, starting in public mental health facilities in
Texas. The researchers are working with 1,440 subjects, and
they hope to have basic information about the results of TMAP
in the fall of this year.
Dr. Rush
focused most of his presentation on the Sequenced Treatment
Alternatives to Relieve Depression (STAR*D), funded by NIMH
as part of a major effort to study real-world treatment on
a large scale. The study will be a five-year research project
involving 4,000 outpatients. First, all participants will
be treated with a standard antidepressant to determine predictors
of response and non-response. Then the researchers will develop
and evaluate clinical strategies to improve outcomes for patients
who do not respond to the initial treatment and compare the
effectiveness, side effects, long-term outcomes, and economic
benefits and costs of different treatment approaches.
Dr. Rush
emphasized that the major aim of treatment for depression
is full remission of the depression. That means not only improvement
of specific symptoms and few, tolerable side effects, but
also improved functioning at home and in the community.
Dr. Gary
Sachs, assistant professor of psychiatry, Harvard Medical
School, described STEP-BD, the Systematic Treatment Enhancement
Program in Bipolar Disorder. STEP-BD is another of the new
long-term, large-scale trials funded by NIMH. It will involve
5,000 patients with bipolar disorder and 100 to 200 clinicians
in 20 or more treatment centers throughout the United States.
Sachs stated that 100 percent of people with a bipolar I diagnosis
have a co-morbid condition, so the study will focus on comorbidity.
The researchers see treatment as an active collaboration between
the treatment team and the research participant.
STEP-BD
is an interesting combination of "optimal clinical care"
(at decision points in the treatment process where there is
general agreement about the best treatment) with randomized
assignment to treatments (at decision points where there is
significant disagreement about the best choice of treatment).
Investigators will also determine the effectiveness of structured
psychotherapies and educating consumers about their illness.
For more
information about the STAR*D or STEP-BP projects, visit the
following Web sites: www.manicdepressive.org
and www.edc.gsph.pitt.edu/stard/.
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