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Editorial
September 2018

The Search for Treatments for Veterans With Major Depression: Of Paramount Importance, yet Still Elusive

Author Affiliations
  • 1Department of Psychiatry and Behavioral Sciences, Miller School of Medicine, University of Miami, Miami, Florida
JAMA Psychiatry. 2018;75(9):877-878. doi:10.1001/jamapsychiatry.2018.1591

Remission rates in patients with major depressive disorder (MDD) remain unacceptably low. From the 28% to 33% remission rate in the Sequenced Treatment Alternatives to Relieve Depression (STAR-D*) Study1 after treatment with the selective serotonin reuptake inhibitor citalopram to the more recent Predicting Response to Depression Treatment (PReDICT) Study2 of treatment-naive patients with depression treated with escitalopram, duloxetine, or cognitive-behavioral therapy (CBT), with remission rates of approximately 50%, it is clear that a sizable number of patients with depression do not achieve remission, the universally acknowledged and desired gold standard of outcome. This is of paramount importance, because patients with depression who do not achieve remission are at greatly increased risk for suicide, drug and alcohol abuse, morbidity, and mortality from several major medical disorders, including stroke, myocardial infarction, diabetes, and others.3 One population at high risk for MDD and repeatedly documented to be relatively resistant to treatment is military veterans.4 Suicide rates are high in this population,5 and comorbidity of MDD with other psychiatric disorders, such as posttraumatic stress disorder (PTSD), is very common.6 A recently published multicenter Veterans Affairs (VA)–sponsored study4 of 1522 patients that compared antidepressant switching with augmentation in patients who had failed at least 1 antidepressant medication resulted in relatively low remission rates (in the range of 22.3% to 28.9%). It is in this context that a large multicenter VA-sponsored study by Yesavage et al7 of repetitive transcranial magnetic stimulation (rTMS), a US Food and Drug Administration–approved treatment for MDD, was undertaken in the VA population.

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