Two prior unsuccessful antidepressant trials usually spell treatment failure with a third, new research suggests. In this scenario, remission rates are less than 20 percent.

The findings of the study, the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, “continue to be sobering,” AJP editor-in-chief Dr. Robert Freedman said in a statement. “By the third wave of the study, the rate of remission continues to be quite low, which underscores the persistence of depression and its resistance to current treatments.”

The focus of the current analysis was to determine which agent, Remeron (mirtazapine) or Pamelor (nortriptyline), was most effective after two consecutive failed medication treatments for depressed outpatients. The study involved 235 adults who had failed treatment with Celexa (citalopram) and then with other antidepressants.

The subjects were randomized to receive Remeron (up to 60 mg/day) or Pamelor (up to 200 mg/day) for 14 weeks, lead author Dr. Maurizio Fava, from Massachusetts General Hospital in Boston, and colleagues note.

Pamelor therapy was associated with a remission rate of roughly 20 percent - higher but not significantly different from the 12 percent rate seen with Remeron. Testing with another self-report measure of depressive symptoms, confirmed that each agent provided similar remission and response rates.

No significant differences in side effects or tolerability were noted between mirtazapine and Pamelor.

“The study has confirmed much of what we suspected, based on industry and federally sponsored clinical trials, case reports, and expert opinion,” Dr. Matthew Menza, from the University of Medicine and Dentistry of New Jersey in Piscataway, notes in a related editorial.

“STAR*D does not answer all of our questions, but progress in science is incremental, and STAR*D has added incrementally to the evidence base for the use of antidepressants.”

SOURCE: American Journal of Psychiatry July 2003.