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STAR*D Objectives Compare relative efficacy of different treatment
options
– Goal is REMISSION, not just “response”
– Less than half of patients with depression remit with a single antidepressant
– Randomized comparisons of treatment options will define the next best step following previous treatment failure(s)
Identify predictors of remission to treatments Utilize simple self-reports as tools to improve
patient collaboration and objectively evaluate treatment response
Rush AJ, et al. Control Clin Trials. 2004;25:119-142.
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STAR*D Study Overview N = 4000 outpatients aged 18 to 75 years old Primary diagnosis of nonpsychotic major
depressive disorder, confirmed by study clinician Most Axis I comorbidities, other general medical
conditions allowed Treatment setting: specialty and primary care HRSD17 score ≥14 at study entry 12–14 weeks per treatment level; 1-year
naturalistic follow-up Equipoise-stratified, randomized design allowed
patients to select treatment strategy and allowed randomization to different treatment options within the selected strategy
Rush AJ, et al. Control Clin Trials. 2004;25:119-142.
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Baseline Demographics
Level 1 Baseline Characteristics of Enrolled Participants (N = 3793): Demographics (03/04)
Primary Care
N = 1560
Specialty Care
N = 2233
Total
N = 3793
Age–Mean (SD) 44 (13) 38 (13) 40 (13)
Female 65% 60% 62%
Race
% white% African American% other% Hispanic
67%21%12%16%
76%14%10%10%
72%17%11%12%
Trivedi MH, et al. Am J Psychiatry. 2006;163:28-40. Courtesy of A. John Rush, MD.
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Baseline Characteristics
Level 1 Baseline Characteristics (N = 3793): Psychiatric History (03/04)
Primary Care
N = 1560
Specialty Care
N = 2233
Total
N = 3793
Age at onset (years) 42 (14) 37 (13) 39 (13)
Number of MDEs (including current episode)
6 (10) 6 (12) 6 (11)
Length of current episode (months)
21 (41) 17 (42) 18 (42)
Length of illness (years)
16 (14) 15 (13) 15 (13)
MDEs = major depressive episodes.Trivedi MH, et al. Am J Psychiatry. 2006;163:28-40. Courtesy of A. John Rush, MD.
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STAR*D Participant Flow into Level 1Screened
(N = 4790)
Ineligible (163) or did not consent (613) (n =
749)
Exit(n = 592)
Follow-up(n = 1083)
Level 2(n = 1201)
a HAM-D = 17-item Hamilton Depression Rating Scale. Adapted from Trivedi MH, et al. Am J Psychiatry. 2006;163:28-40.
Failed to return(n = 234)
Enrolled in Level 1
(n = 4041)
HAM-D score >14
(n = 3110)
Eligible for analysis(n = 2876)
HAM-D score <14a
(n = 607)or HAM-D missing
(n = 324)
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SWITCH OPTIONSRandomized
STAR*D Defining Evidence for Protocols—Level II
AUGMENT OPTIONSRandomized
COGN = 204
CIT + BUSN = 354
CIT + COGN = 224
BUP-SRN = 287
VEN-XRN = 287
Nonremitters treated w/ CITLevel 1:
Level 2:
BUP-SR, bupropion sustained-release; BUS, buspirone; CIT, citalopram; COG, cognitive therapy; SER: sertraline; VEN-XR, venlafaxine extended-releaseSTAR-D III Research Design Methods.pdf. Available at: http://edc.gsph.pitt.edu/stard/public/Protocol/. Accessed June 25, 2008.
Randomized to BUP-SR or VEN-XRLevel 2A:
If no satisfactory response to COG, then L2A
SERN = 287
CIT + BUP-SRN = 354
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Observations Clinical presentation of patients with major depressive
disorder (MDD) in primary and specialty care is similar General medical conditions minimally affect MDD
symptoms Substance abuse minimally affects MDD symptoms Psychiatric comorbidities complicate remission MDD + substance abuse is more likely in younger males,
but not more likely by ethnicity Patients with early-onset MDD have more severe,
disabling, chronic, or recurrent conditions Patients with early-onset MDD have more comorbidities,
poorer educational achievement, and lower likelihood of marriage
1. Warden D, et al. Curr Psychiatry Rep. 2007;9:449-459. 2. Rush AJ, et al. Am J Psychiatry. 2006;163:1905-1917. 3. Trivedi MH, et al. Neuropsychopharmacology. 2007;32:2479-2489. 4. NIMH/Results for STAR*D Study. http://www.nimh.nih.gov/health/trials/practical/stard/index.shtml. Accessed April 2, 2008. 5. Rush AJ, et al. Psychiatric Annals. 2008;38:188-193.
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Clinical Implications STAR*D provides new evidence to choose among
treatment decisions for patients with major depressive disorder
Maximum tolerated dose and lengthier dosing time may be needed to achieve remission– 8–14 weeks adherence to treatment, including 4 weeks at
maximum tolerated dose, was required
– If QIDS score is not reduced by 25% by week 9, participants recommended to move to the next level
– About half of the participants became symptom-free after the first 2 treatment levels
Measurement-based tools improve adherence to therapy through patient education and collaboration– Measure symptoms/side effects at each visit
1. Warden D, et al. Curr Psychiatry Rep. 2007;9:449-459. 2. Rush AJ, et al. Am J Psychiatry. 2006;163:1905-1917. 3. Trivedi MH, et al. Neuropsychopharmacology. 2007;32:2479-2489. 4. NIMH/Results for STAR*D Study. http://www.nimh.nih.gov/health/trials/practical/stard/index.shtml. Accessed April 2, 2008. 5. Rush AJ, et al. Psychiatric Annals. 2008;38:188-193.
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Suggested Reading
World Health Organization. Depression. Available at: http://www.who.int/mental_health/management/depression/definition/en/. Accessed April 9, 2008.
Greenberg PA, Kessler RC, Birnbaum HG, et al. The economic burden of depression in the United States: how did it change between 1990 and 2000? J Clin Psychiatry. 2003;64:1465-1475.
Trivedi MH, Rush AJ, Gaynes BN, et al. Maximizing the adequacy of medication treatment in controlled trials and clinical practice: STAR*D measurement-based care. Neuropsychopharmacology. 2007;32:2479-2489.
National Institute of Mental Health. Results for Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study. Available at: http://www.nimh.nih.gov/health/trials/practical/stard/index.shtml. Accessed April 2, 2008.
Warden D, Rush AH, Trivedi MH, Fava M, Wisniewski SR. The STAR*D project results: a comprehensive review of findings. Curr Psychiatry Rep. 2007;9:449-459.
Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry. 2006;163:1905-1917.