Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report

Summary & key facts

This study followed adults with major depression who tried up to four different treatment steps when earlier ones did not fully help. About 3,700 people began the study and roughly 120 reached a fourth step. Remission — meaning almost no depressive symptoms — happened in about 37% after the first step, 31% after the second, and about 14% after the third and fourth steps. Altogether, about two-thirds of people reached remission at some point. People who needed more treatment steps were less likely to reach remission and were more likely to relapse during the one-year follow-up. The researchers say we need better treatments and smarter ways to choose treatment sequences for each person.

Key facts:

• The study followed a large group of adults treated as outpatients for major depression. About 3,700 people started treatment and about 120 reached a fourth treatment step.
• Patients who did not get better or could not tolerate a treatment were encouraged to move to the next step. Those who had an acceptable benefit could enter a 12-month follow-up period.
• Remission — defined in the study as having almost no depressive symptoms — occurred in about 37% of people after the first treatment step.
• Remission rates were about 31% after the second step, and fell to about 14% after the third and fourth steps.
• When all steps were counted together, roughly two-thirds of participants reached remission at some point during the study.
• People who needed more treatment steps had higher relapse rates during the one-year follow-up than people who needed fewer steps.
• Among people entering the follow-up phase, those who were already in remission had lower relapse rates than those who were not in remission after the first three steps.
• The authors concluded that current multistep approaches often lead to lower success in later steps and higher chances of relapse, and they called for research to find better treatments and better sequences of treatments for individuals.

Abstract

OBJECTIVE: This report describes the participants and compares the acute and longer-term treatment outcomes associated with each of four successive steps in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial. METHOD: A broadly representative adult outpatient sample with nonpsychotic major depressive disorder received one (N=3,671) to four (N=123) successive acute treatment steps. Those not achieving remission with or unable to tolerate a treatment step were encouraged to move to the next step. Those with an acceptable benefit, preferably symptom remission, from any particular step could enter a 12-month naturalistic follow-up phase. A score of <or=5 on the Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR(16)) (equivalent to or=11 (HRSD(17)>or=14) defined relapse. RESULTS: The QIDS-SR(16) remission rates were 36.8%, 30.6%, 13.7%, and 13.0% for the first, second, third, and fourth acute treatment steps, respectively. The overall cumulative remission rate was 67%. Overall, those who required more treatment steps had higher relapse rates during the naturalistic follow-up phase. In addition, lower relapse rates were found among participants who were in remission at follow-up entry than for those who were not after the first three treatment steps. CONCLUSIONS: When more treatment steps are required, lower acute remission rates (especially in the third and fourth treatment steps) and higher relapse rates during the follow-up phase are to be expected. Studies to identify the best multistep treatment sequences for individual patients and the development of more broadly effective treatments are needed.

Topics

Digital Mental Health Interventions Psychotherapy Techniques and Applications Treatment of Major Depression

Categories

Health Sciences Medicine Pharmacology

Tags

Astronomy Astrophysics Intensive care medicine Medicine Physics Psychiatry Psychology Star (game theory) Term (time)

Conditions & symptoms

Depression Difficulty focusing Lack of energy or motivation Poor sleep Sadness or low mood