Am J Psychiatry 163:28-40, January 2006
doi: 10.1176/appi.ajp.163.1.28
© 2006 American Psychiatric Association
Evaluation of Outcomes With Citalopram for Depression Using Measurement-Based Care in STAR*D: Implications for Clinical Practice
Madhukar H. Trivedi, M.D.,
A. John Rush, M.D.,
Stephen R. Wisniewski, Ph.D.,
Andrew A. Nierenberg, M.D.,
Diane Warden, Ph.D., M.B.A.,
Louise Ritz, M.B.A.,
Grayson Norquist, M.D.,
Robert H. Howland, M.D.,
Barry Lebowitz, Ph.D.,
Patrick J. McGrath, M.D.,
Kathy Shores-Wilson, Ph.D.,
Melanie M. Biggs, Ph.D.,
G. K. Balasubramani, Ph.D., and
Maurizio Fava, M.D.
STAR*D Study Team
OBJECTIVE: Selective serotonin reuptake inhibitors (SSRIs) are widely used to treat depression, but the rates, timing, and baseline predictors of remission in "real world" patients are not established. The authors’ primary objectives in this study were to evaluate the effectiveness of citalopram, an SSRI, using measurement-based care in actual practice, and to identify predictors of symptom remission in outpatients with major depressive disorder. METHOD: This clinical study included outpatients with major depressive disorder who were treated in 23 psychiatric and 18 primary care "real world" settings. The patients received flexible doses of citalopram prescribed by clinicians for up to 14 weeks. The clinicians were assisted by a clinical research coordinator in the application of measurement-based care, which included the routine measurement of symptoms and side effects at each treatment visit and the use of a treatment manual that described when and how to modify medication doses based on these measures. Remission was defined as an exit score of  7 on the 17-item Hamilton Depression Rating Scale (HAM-D) (primary outcome) or a score of 5 on the 16-item Quick Inventory of Depressive Symptomatology, Self-Report (QIDS-SR) (secondary outcome). Response was defined as a reduction of  50% in baseline QIDS-SR score. RESULTS: Nearly 80% of the 2,876 outpatients in the analyzed sample had chronic or recurrent major depression; most also had a number of comorbid general medical and psychiatric conditions. The mean exit citalopram dose was 41.8 mg/day. Remission rates were 28% (HAM-D) and 33% (QIDS-SR). The response rate was 47% (QIDS-SR). Patients in primary and psychiatric care settings did not differ in remission or response rates. A substantial portion of participants who achieved either response or remission at study exit did so at or after 8 weeks of treatment. Participants who were Caucasian, female, employed, or had higher levels of education or income had higher HAM-D remission rates; longer index episodes, more concurrent psychiatric disorders (especially anxiety disorders or drug abuse), more general medical disorders, and lower baseline function and quality of life were associated with lower HAM-D remission rates. CONCLUSIONS: The response and remission rates in this highly generalizable sample with substantial axis I and axis III comorbidity closely resemble those seen in 8-week efficacy trials. The systematic use of easily implemented measurement-based care procedures may have assisted in achieving these results.
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Ann. Pharmacother.,
December 1, 2006;
40(12):
2115 - 2122.
[Abstract]
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J. C. Nelson
The STAR*D Study: A Four-Course Meal That Leaves Us Wanting More
Am J Psychiatry,
November 1, 2006;
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A. J. Rush, M. H. Trivedi, S. R. Wisniewski, A. A. Nierenberg, J. W. Stewart, D. Warden, G. Niederehe, M. E. Thase, P. W. Lavori, B. D. Lebowitz, et al.
Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report
Am J Psychiatry,
November 1, 2006;
163(11):
1905 - 1917.
[Abstract]
[Full Text]
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S. Zisook
Ask the Expert PSYCHOPHARMACOLOGY: MAJOR DEPRESSIVE DISORDER
Focus,
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4(4):
484.
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M. Valenstein
Keeping Our Eyes on STAR{star}D
Focus,
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M. Menza
STAR{star}D: The Results Begin to Roll in
Focus,
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M. Valenstein
Keeping Our Eyes on STAR*D
Am J Psychiatry,
September 1, 2006;
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1484 - 1486.
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F. V. deGruy III
A Note on the Partnership Between Psychiatry and Primary Care
Am J Psychiatry,
September 1, 2006;
163(9):
1487 - 1489.
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A. A. Nierenberg, M. Fava, M. H. Trivedi, S. R. Wisniewski, M. E. Thase, P. J. McGrath, J. E. Alpert, D. Warden, J. F. Luther, G. Niederehe, et al.
A Comparison of Lithium and T3 Augmentation Following Two Failed Medication Treatments for Depression: A STAR*D Report
Am J Psychiatry,
September 1, 2006;
163(9):
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P. J. McGrath, J. W. Stewart, M. Fava, M. H. Trivedi, S. R. Wisniewski, A. A. Nierenberg, M. E. Thase, L. Davis, M. M. Biggs, K. Shores-Wilson, et al.
Tranylcypromine Versus Venlafaxine Plus Mirtazapine Following Three Failed Antidepressant Medication Trials for Depression: A STAR*D Report
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K. W. Davidson, D. J. Kupfer, J. T. Bigger, R. M. Califf, R. M. Carney, J. C. Coyne, S. M. Czajkowski, E. Frank, N. Frasure-Smith, K. E. Freedland, et al.
Assessment and treatment of depression in patients with cardiovascular disease: national heart, lung, and blood institute working group report.
Psychosom Med,
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645 - 650.
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A. C. M. Vergouwen
Initial rate of improvement in major depression
The British Journal of Psychiatry,
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M. Menza
STAR*D: The Results Begin to Roll in
Am J Psychiatry,
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M. Fava, A. J. Rush, S. R. Wisniewski, A. A. Nierenberg, J. E. Alpert, P. J. McGrath, M. E. Thase, D. Warden, M. Biggs, J. F. Luther, et al.
A Comparison of Mirtazapine and Nortriptyline Following Two Consecutive Failed Medication Treatments for Depressed Outpatients: A STAR*D Report
Am J Psychiatry,
July 1, 2006;
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R. Hierholzer
Remission Rates for Depression in STAR*D Study
Am J Psychiatry,
July 1, 2006;
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M. A. Whooley
Depression and cardiovascular disease: healing the broken-hearted.
JAMA,
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N. Sussman, S. C. Williams, L. Tebartz van Elst, D. Ebert, B. Hesslinger, A. J. Rush, M. H. Trivedi, S. R. Wisniewski, the STAR*D trial investigators, and D. R. Rubinow
Depression--augmentation or switch after initial SSRI treatment.
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Multiple Levels of Drug Treatment for Depression
Journal Watch Dermatology,
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J. E. Alpert
Improving depression outcome: new concepts, strategies and technologies
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R. S. McIntyre, J. Z. Konarski, and S. H. Kennedy
One size fits all?
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Multiple Levels of Drug Treatment for Depression
Journal Watch (General),
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A. J. Rush, M. H. Trivedi, S. R. Wisniewski, J. W. Stewart, A. A. Nierenberg, M. E. Thase, L. Ritz, M. M. Biggs, D. Warden, J. F. Luther, et al.
Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression.
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March 23, 2006;
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M. H. Trivedi, M. Fava, S. R. Wisniewski, M. E. Thase, F. Quitkin, D. Warden, L. Ritz, A. A. Nierenberg, B. D. Lebowitz, M. M. Biggs, et al.
Medication augmentation after the failure of SSRIs for depression.
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354(12):
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D. R. Rubinow
Treatment strategies after SSRI failure--good news and bad news.
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M. M. Weissman, D. J. Pilowsky, P. J. Wickramaratne, A. Talati, S. R. Wisniewski, M. Fava, C. W. Hughes, J. Garber, E. Malloy, C. A. King, et al.
Remissions in Maternal Depression and Child Psychopathology: A STAR*D-Child Report
JAMA,
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J. R. DePaulo Jr.
Bipolar Disorder Treatment: An Evidence-Based Reality Check
Am J Psychiatry,
February 1, 2006;
163(2):
175 - 176.
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