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

Summary & key facts

Researchers followed adults with major depression who tried one to four different treatment steps in a large study called STAR*D. Each step gave people a chance to find a treatment that made their symptoms very low. About two-thirds of people eventually reached that low-symptom state, but success fell a lot after the first two steps and people who needed more steps tended to get worse again more often during a year of follow-up.

Key facts:

• The study looked at outpatients with nonpsychotic major depression who could move to the next treatment step if the current one did not bring remission or was not tolerated.
• About 3,700 people started the first treatment step, and 123 people went on through four steps.
• Remission rates after each acute step were about 37% for the first step, about 31% for the second, about 14% for the third, and about 13% for the fourth.
• Overall, about two-thirds of people reached remission at some point across the steps.
• People who needed more treatment steps were more likely to relapse, meaning their symptoms rose again, during the 12-month follow-up period.
• Participants who were in remission when they began the follow-up had lower relapse rates than those who were not in remission after the first three steps.
• The authors say we need better overall treatments and more research to find which sequences of treatments work best for different people.

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 Lack of energy or motivation Poor sleep Sadness or low mood