Despite extensive study and several generations of well-marketed drugs, treating depression is still kind of crapshoot. About half of patients don't respond to the first two antidepressants they're prescribed. In one study, a doctor moved patients through a sequence of options, as psychiatrists often do—switching drugs, adding drugs, using atypical throwback drugs—and 53 percent showed no or minimal improvement at the end. Research suggests that cognitive behavioral therapy works about as well as pharmacologic treatments for depression, but investigators are foggy as to why and, more importantly, who would be a good candidate for which option.
Now, a team at Emory University has found that an MRI scan might be helpful in deciding which course of treatment would be more effective.
For a study called Predictors of Remission in Depression to Individual and Combined Treatments, or PReDICT, researchers randomly assigned 344 people with depression to either 12 weeks of treatment with antidepressants or with cognitive behavioral therapy (CBT), an approach to talk therapy that revolves around examining the relationships between people's thoughts and their behaviors. Participants filled out the 17-item Hamilton Depression Rating Scale at the beginning and the end of the study.
Also at the start of the study, the team got a look at the inner workings of 122 people's brains via MRI scans. In the first of two papers published last week in the American Journal of Psychiatry, the researchers reported that patients whose MRIs showed greater connectivity in regions of the brain that process emotion were significantly more likely to achieve remission from sitting down with a therapist for CBT, while patients with poor or absent connectivity in those regions were more likely to improve with medication.
It's worth mentioning that there wasn't a control group of people who didn't receive treatment and researchers also didn't test combining medications and CBT; pairing up drugs and psychotherapy in general (not CBT) has been shown to be more effective than treating with just one of the two.
Helen Mayberg, a psychiatry professor at the Emory University School of Medicine, said in a press release that treating depression can be similar to treating cancer, where biological indicators guide medical decisions. "[D]ifferent types of depression will require specific treatments," she said. "Using these scans, we may be able to match a patient to the treatment that is most likely to help them, while avoiding treatments unlikely to provide benefit."
For a separate paper, the researchers also asked the PReDICT subjects at the outset which treatment they'd prefer: therapy or meds. That's because current guidelines suggest that mental health professionals consider their patients' preferences when selecting a treatment approach.
They found that people who didn't get assigned to their desired method were more likely to drop out of the study, but among those who stuck it out, people's preferences were only weakly associated with remission rates. Meaning, the brain scans were better at predicting which treatment would work.
Notably, the PReDICT study touts a more diverse patient base than most psychological research. The authors recruited patients from the Atlanta area that's home to Emory and about half of participants identified as black or Latinx.
Thanks to a complex mix of brain chemistry, personal history, and other issues that play a role in depression, there will probably never be a one-size-fits-all treatment, but perhaps diagnostic methods like brain scans could spare suffering people the frustration of trying to feel better and getting nowhere.
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