To the Editor: The less than spectacular remission rates for depression recently reported in The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study (1) will likely be of no surprise to experienced clinicians. I, for one, am relieved to find that the frustratingly poor remission rates that I’ve witnessed for many years among my depressed patients (most of whom are characterized by features associated in the study with lower remission rates) are in accord with a well-designed effectiveness study such as STAR*D. The STAR*D study is a welcome change from the era of efficacy studies in which patients like mine were largely excluded.
The “real world” findings of the STAR*D study pose thought-provoking questions concerning how we think about and promote treatments for depression. Much of the current promotional and educational literature on depression is infused with the more optimistic response (not remission) figures derived from older antidepressant efficacy studies. Certainly, much of the promotional literature emanating from the pharmaceutical industry seems to promise better results with antidepressants than those obtained in STAR*D. I doubt that any pharmaceutical company would want it to be said that their antidepressant appears to be “only sufficient for a minority of patients, particularly high functioning, well-educated women with few comorbid psychiatric or medical problems” (2, p. 6). Even information from an APA informational website (www.healthyminds.org) on the treatment of depression, although no doubt technically accurate, seems to gloss over the unpleasant realities of the limitations in our treatments: “between 80%–90% of people with depression eventually respond well to treatment.”
We don’t serve anyone well by overselling what we have to offer. My clinical sense is that “real world” patients are often perplexed when they don’t rapidly achieve a spectacular response from their medication, whatever it is. It is worth debating when our desire to impart hope becomes downright misleading to patients and their families and when overly optimistic pronouncements about the effectiveness of our treatments undercut our pleas for additional funding to study a wide range of treatment interventions for depression and other mental disorders, especially those interventions that may lack the financial backing of industry. Obviously, this initial report from the STAR*D study is not the end of the matter, and it is important to note that the report suggests interventions that might yield higher remission rates (1). I look forward to subsequent publications from STAR*D that will, hopefully, help us to better educate the public about what to expect from medications and what best to do when our patients are not among the minority who fully remit with the first medication that they try.
1.Trivedi M, Rush AJ, Wisniewski SR, Nierenberg AA, Warden D, Ritz L, Norquist G, Howland RH, Lebowitz B, McGrath PJ, Shores-Wilson K, Biggs MM, Balasubramani GK, Fava M, STAR*D Study Team: Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice. Am J Psychiatry 2006; 163:28–402.Insel TR: Beyond efficacy: the STAR*D trial. Am J Psychiatry 2006; 163:5–7