Management strategies for major depressive episodes as a function of initial response to an SSRI or SNRI antidepressant: results of the ORACLE survey
Spadone C, Sylvestre M, Chiarelli P, Richard-Berthe C.
Hopital Saint-Louis (AP-HP), Paris.
Encephale. 2005 Nov-Dec;31(6 Pt 1):698-704


Objective - The main aim of the major depressive episode treatment is to obtain a complete remission. However, partial remission (persistence of residual symptoms) is a frequent outcome of major depressive episodes, concerning approximately half of the patients who were responders to the treatment. An inadequate treatment response after three weeks of treatment is considered by the ANAES recommendations as a potential reason to modify the treatment regimen. The primary objectives of this survey were to describe the therapeutic strategies implemented in subjects treated as outpatients for a major depressive episode following evaluation of the initial response to an SSRI or an SNRI antidepressant and to assess by a naturalistic way the impact of these strategies on the extent of remission at three months. The secondary objective was to determine, by multivariate analysis, others factors able to influence the remission. Methods - This prospective observational survey concerned 2 138 patients treated by community psychiatrists (n=582) and presenting a major depressive episode in the context of a recurrent depressive disorder. Patients were assessed at inclusion and at Weeks 3, at Week 6 and at Week 12. Changes in score on the Hamilton Depression Scale (Ham-D) and CGI severity between inclusion and Week 3 and improvement scores were evaluated. The therapeutic strategies after evaluation were described. Remission was defined as a score of 1 or 2 on the CGI-improvement scale; a treatment response at Week 3 was defined as a decrease of at least 50% in the Ham-D score. The physician also provided an overall rating of satisfaction with the treatment at Week 3. Results - Data from 1 974 patients were analysed. The mean age at inclusion was 42.7 years, 70% of the patients were women; the mean age at first episode was 32.2 years, the average time since the last episode was 3.6 years. The mean Ham-D score at inclusion was 23.6 +/- 5.8. At Week 3, 29.1% of patients were considered treatment responders. The antidepressant dose was subsequently increased in 10.2% of responders compared to 36.3% of non-responders. When the physician rated the treatment response as unsatisfactory, the dose was increased in 56% of cases. At week 12, 83.7% of patients were in remission as defined by the CGI; according to physician judgement, 45.7% were in complete remission and 43.3% in partial remission. According to the literature, the existence of an early response to the treatment predicted a total remission at Week 12 (69.1% of the treatments responders at Week 3 were in complete remission at Week 12, vs 35.7% of the treatments not-responders). Conclusion - These results underline the professional practices in private community psychiatric practice in France. At Week 3, posology increased for only 36.3% of the patients, whereas it is one of the therapeutic strategies recommended by the ANAES. Participating physicians relied on their subjective judgement about initial treatment response when making decisions about treatment strategies rather than by psychometric scores. At Week 3, 29.1% of patients were considered treatment responders according to the change in Ham-D score, compared to 57.3% whose treatment response was considered satisfactory by the physician. The decision to increase the dose was more closely associated with subjective perceptions of satisfaction than with psychometric rating scale scores, despite psychometric evaluation was systematic in the ORACLE survey, what is not the case in usual practice in France, except for clinical research. In addition, this study confirms an important data for the clinician: there is a correlation between early response to the treatment (Week 3) and complete remission at the end of the acute phase of treatment (Week 12).
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