STAR*D

Last updated
STAR*D
Study typeCollaborative study on the treatment of depression
Dates2006
Locations23 psychiatric and
18 primary care sites
Funding National Institute of Mental Health

Sequenced Treatment Alternatives to Relieve Depression (STAR*D) was a collaborative study on the treatment of depression, funded by the National Institute of Mental Health. Its main focus was on the treatment of depression in patients where the first prescribed antidepressant proved inadequate. A key feature of the study was its aim to be more generalizable to real clinical situations; this was done through the use of minimal exclusion criteria, incorporating patient preference, and not blinding the treatments (i.e. the patient and clinician both knew what treatment the patient was receiving). [1] The STAR*D trial included remission (the near-absence of symptoms, rather than simply a reduction in symptoms) as an outcome measure, as there is evidence that patients with depression who achieve remission function better and are less prone to relapse than those who achieve only partial improvement in symptoms [1]

Contents

This report had profound impact on the promotion of antidepressants but later accused of having been subjected to multiple levels of fraud. [2]

Trial

The STAR*D trial enrolled 4,041 outpatients with nonpsychotic depression at 23 psychiatric and 18 primary care sites. [3] The trial was completed in 2006, and data from it has been available since 2008.

The trial involved four different treatment levels, and patients were encouraged to enter the next level of treatment if they failed to achieve remission or response (50% reduction in symptoms) after a specified number of weeks. [1]

In level one, patients received the selective serotonin reuptake inhibitor (SSRI) citalopram for up to 14 weeks, with adjustment of the dose being managed by their own physicians. [1] If patients achieved remission or response during that time period, they could enter a 12-month naturalistic follow-up, during which time the researchers did not have any influence over the treatment plan. [1] [4] Non-remitters were encouraged to enter level two.

In level two, there were seven different treatment options, and cognitive behavioral therapy (CBT) was included as the psychotherapy option. There were three combination options (either an antidepressant or CBT added to citalopram), and four switch options (to either a different antidepressant or CBT). [1] Those who remitted or responded were offered 12-month naturalistic follow-up; non-remitters after two medication trials were encouraged to enter level 3; other non-remitters entered level 2A, which involved a second antidepressant trial. [1]

In level three, patients were offered the addition of lithium or triiodothyronine (a thyroid hormone) to their antidepressant, or a switch to another antidepressant (mirtazapine or nortriptyline). [1] This continued for 12 weeks.

Level four consisted of the monoamine oxidase inhibitor tranylcypromine or a combination of venlafaxine and mirtazapine. [1]

Results

For level one, the remission rate was 28-33% (depending on the symptom scale used), and the response rate was 47%. [5] Higher remission rates were seen in patients who were Caucasian, female, employed, or had higher levels of income or education. [5] Lower remission rates were seen in those with longer depressive episodes, co-occurring anxiety or substance use disorders, and more physical illness. [5]

For level two, patients who received CBT, either alone or combined with citalopram, had similar response and remission rates compared to those who were receiving medication(s) only; however, for those patients who remained on citalopram, those who had another antidepressant added achieved remission more rapidly than those who had CBT added. [5] Among the patients who were switched to a different antidepressant, there was no significant difference among the different antidepressants.

For level three, the remission rates based on the HAM-D symptom scale were 12.3% for mirtazapine and 19.8% for nortriptyline, although the difference was not large enough for statistical significance. [5] The remission rates based on the HAM-D in the combination strategy were 15.9% for lithium and 24.7% for triiodothyronine, but the difference was not statistically significant. [5] However, more patients receiving lithium than triiodothyronine left the study due to side effects. [5]

For level four, the average remission rate was 13%, with no statistically significant difference between tranylcypromine and the venlafaxine/mirtazapine combination. [5] More patients receiving tranylcypromine left the study due to side effects. [5]

Overall, the study findings indicate that patients who do not achieve remission or response after several weeks of citalopram treatment could achieve those outcomes by the end of 14 weeks. [1] The STAR*D researchers state that their data "suggest that a patient with persistent depression can get well after trying several treatment strategies, but his or her odds of beating the depression diminish as additional treatment strategies are needed." [6] With failed treatment at a higher step, the chances of remission were smaller – and this decrease was particularly significant after level two. [1] For those who did achieve full remission, there was a decreased chance of relapse at 12-month (naturalistic) follow-up compared to those patients who only responded. [1]

A reanalysis published in 2023 concluded that STAR*D’s cumulative remission rate was approximately half of that reported. [7]

Criticism

Criticism of bias has been raised by certain researchers about the STAR*D trial: [8]

See also

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References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 Sinyor M, Schaffer A, Levitt A (2010). "The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Trial: A Review". The Canadian Journal of Psychiatry. 55 (3): 126–135. doi:10.1177/070674371005500303. PMID   20370962. S2CID   19442084.
  2. ↑ https://bmjopen.bmj.com/content/13/7/e063095
  3. ↑ Insel, Thomas R., M.D. (2006). "Beyond Efficacy: The STAR*D Trial". Blog Publication by the NIMH Director. 163 (1). National Institute of Mental Health: 5–7. doi:10.1176/appi.ajp.163.1.5. PMC   1586101 . PMID   16390879. Archived from the original on 2014-04-04. Retrieved 4 April 2014.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  4. ↑ BS, Amanda Stevens (2023-02-10). "Does Adderall Help With Depression?". New Waters Recovery. Retrieved 2023-04-15.
  5. 1 2 3 4 5 6 7 8 9 Howland RH (2008). "Sequenced Treatment Alternatives to Relieve Depression (STAR*D)--Part 2: Study Outcomes". Journal of Psychosocial Nursing and Mental Health Services. 46 (10): 21–24. doi:10.3928/02793695-20081001-05. PMID   18935932.
  6. ↑ "STAR*D: Latest News". Project website for NIMH-funded collaborative study on the treatment of depression. University of Pittsburgh. Archived from the original on 5 March 2013. Retrieved 10 February 2013.
  7. ↑ "What are the treatment remission, response and extent of improvement rates after up to four trials of antidepressant therapies in real-world depressed patients? A reanalysis of the STAR*D study's patient-level data with fidelity to the original research protocol". PubMed Central. July 25, 2024.
  8. 1 2 3 Pigott, H. E. (2011). STAR*D: A tale and trail of bias Ethical Human Psychology and Psychiatry: An International Journal of Critical Inquiry, 13(1), 6-28. https://doi.org/10.1891/1559-4343.13.1.6.
  9. ↑ Robert Whitaker (2010) The STAR*D Scandal: A New Paper Sums It All Up Psychology Today "Thus, if the study protocol had been followed and the results honestly reported, the researchers would have announced that 38% of the patients remitted during the four steps of treatment, and that the remaining 62% either dropped out or failed to remit."
  10. ↑ Leventhal, A. M., & Antonuccio, D. O. (2009). On chemical imbalances, antidepressants, and the diagnosis of depression. Ethical Human Psychology and Psychiatry, 11(3), 199. DOI: https://doi.org/10.1891/1559-4343.11.3.199 "Although the study’s reports make no mention of this outcome, their data show that after a year of continuation treatment following remission, of the 4,041 patients who entered the program only 108 (3%) had a sustained remission — all the other patients either dropped out or relapsed" p. 205, pdf p. 7.
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