To the Editor: The patient perspective in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study of lithium and T3 augmentation described a 44-year-old white female who became depressed after she lost her job (1). At one time such patients were diagnosed as having a reactive depression, with anger at what had happened being redirected at the self, causing both depression and later shame. The treatment was psychotherapy to release the anger and to help the patient regain a sense of self. The same dramatic result was described in the vignette, with the patient feeling as if her brain were “functioning again.” This formulation is not without its critics. Some critics of this view would say that several weeks of psychotherapy may provide sufficient time for the disease to run its natural course, as opposed to any direct effect of the psychotherapy per se. Regardless of which view is correct, I wonder if some patients in the STAR*D trials might have suffered similar anger and shame and therefore not responded to drug therapy, which could partly explain the low remission rates observed.
Dr. Heath reports no competing interests.