Scan of the Insula Predicts Whether CBT or SSRI's Will Best Lift Depression

Scan Predicts Whether Therapy or Meds Will Best Lift Depression
http://www.sciencedaily.com/releases/2013/06/130612162358.htm

Currently, determining whether a particular patient with depression would best respond to psychotherapy or medication is based on trial and error. In the absence of any objective guidance that could predict improvement, clinicians typically try a treatment that they, or the patient, prefer for a month or two to see if it works. Consequently, only about 40 percent of patients achieve remission following initial treatment. This is costly in terms of human suffering as well as health care spending.

one specific brain area emerged as a pivotal predictor of outcomes from two standard forms of depression treatment: cognitive behavior therapy (CBT) or escitalopram, a serotonin specific reuptake inhibitor (SSRI) antidepressant. If a patient's pre-treatment resting brain activity was low in the front part of an area called the insula, on the right side of the brain, it signaled a significantly higher likelihood of remission with CBT and a poor response to escitalopram. Conversely, hyperactivity in the insula predicted remission with escitalopram and a poor response to CBT.


What I find most intersting about this, is that one is a hyperreactivity and the other a hyporeactivity, it almost suggests two inverse conditions. One which CBT talk therapy will help, and another where drug treatment with an SSRI and probable increases in seretonin or BDNF will help?! Most of us would predict them to work on similar pathways, not for distinct conditions! Indeed, I was always under the impression that CBT WITH and SSRI would be most efficacious, this suggests otherwise, and that both together would be pointless for most people, with people's treatment choice depending on their insula reactivity.


Among several sites of brain activity related to outcome, activity in the anterior insula best predicted response and non-response to both treatments. The anterior insula is known to be important in regulating emotional states, self-awareness, decision-making and other thinking tasks. Changes in insula activity have been observed in studies of various depression treatments, including medication, mindfulness training, vagal nerve stimulation and deep brain stimulation.

"If these findings are confirmed in follow-up replication studies, scans of anterior insula activity could become clinically useful to guide more effective initial treatment decisions, offering a first step towards personalized medicine measures in the treatment of major depression" said Mayberg.