STAR*D: Lessons learned for primary care

The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, the largest prospective treatment study of depression ever conducted, addresses the question of how to proceed when a depressed patient does not adequately respond to one or more treatment attempts. The study enrolled 4,041 patients with major depressive disorder in 18 primary care and 23 psychiatric care clinics, with no difference in depression severity seen between psychiatric and primary care sites. Approximately 33% of depressed patients who were initially treated with the selective serotonin reuptake inhibitor citalopram attained clinical remission. For nonremitters, subsequent medication switch and augmentation strategies produced modest remission rates. Patients whose depressions fully remitted were less likely to relapse than those who experienced only response without remission. Using measurement-based care strategies, remission rates were similar for patients seen in psychiatric and primary care settings.