The first patient to receive a modern antidepressant was Paula J. F., a Swiss woman admitted to the Munsterlingen asylum with depression.

The latest foray into the controversial issue of antidepressant-induced switching appeared in the February issue of The American Journal of Psychiatry (2006;163:232-239). The last time TCPR took up this topic (June 2005), we reviewed a meta-analysis of antidepressant use in bipolar disorder. That paper concluded that SSRIs cause the same rate of manic switching as placebo (Am J Psychiatry 2004;161:1537-1547). The authors of the newly published research would beg to differ.

While it’s certainly interesting to theorize about neurotransmitters and antidepressants, the recent STAR*D findings bring up a difficult topic: Does mechanism matter?

When National Public Radio’s Science Friday devotes most of a program to a psychiatric study, it must be newsworthy. The STAR*D study got this special treatment recently, with Ira Flato interviewing John Rush about the ins and outs of the NIMH-funded project.

Because the first results from STAR*D make antidepressants look less powerful than we might have hoped, researchers have emphasized another aspect of the study – namely, that it represents a system that allows us to bring research techniques into our practices. A review of the STAR*D treatment manual is a useful exercise.

Dr. Rush, thanks for agreeing to help us understand the STAR*D trial. You were the overall principal investigator of what I believe was the largest study in history comparing different antidepressants. Looking at the first set of results, are you encouraged by the findings?

Vagus nerve stimulation (VNS) is certainly new—but is it effective? It took the FDA a long time to make up its mind, but eventually it approved the treatment in May 2005. (For more details on why the FDA flip-flopped on the issue, see “FDA Approval of VNS,” this issue.) In this article, we scrutinize the two pivotal studies leading to approval.

First they said yes to VNS, then no, then yes. And now they’re trying desperately to explain their final answer.

If, after reviewing our admittedly lukewarm evaluation of the VNS data, you decide that you want to offer it to your patients, here’s some useful information.

Most psychiatrists pretty much agree that all antidepressants are more or less equally effective. So if you start with that premise and you have 10-15 antidepressants out there, why are you picking one versus another? And what algorithm are we all using? Dr. Zimmerman developed a questionnaire for psychiatrists to fill out immediately after they wrote antidepressant prescriptions. We asked, “What influenced you to choose that medication?”