title: Sequenced treatment alternatives to relieve depression (STAR*D): rationale and design.
abstract: STAR*D is a multisite, prospective, randomized, multistep clinical trial of outpatients with nonpsychotic major depressive disorder. The study compares various treatment options for those who do not attain a satisfactory response with citalopram, a selective serotonin reuptake inhibitor antidepressant. The study enrolls 4000 adults (ages 18-75) from both primary and specialty care practices who have not had either a prior inadequate response or clear-cut intolerance to a robust trial of protocol treatments during the current major depressive episode. After receiving citalopram (level 1), participants without sufficient symptomatic benefit are eligible for randomization to level 2 treatments, which entail four switch options (sertraline, bupropion, venlafaxine, cognitive therapy) and three citalopram augment options (bupropion, buspirone, cognitive therapy). Those who receive cognitive therapy (switch or augment options) at level 2 without sufficient improvement are eligible for randomization to one of two level 2A switch options (venlafaxine or bupropion). Level 2 and 2A participants are eligible for random assignment to two switch options (mirtazapine or nortriptyline) and to two augment options (lithium or thyroid hormone) added to the primary antidepressant (citalopram, bupropion, sertraline, or venlafaxine) (level 3). Those without sufficient improvement at level 3 are eligible for level 4 random assignment to one of two switch options (tranylcypromine or the combination of mirtazapine and venlafaxine). The primary outcome is the clinician-rated, 17-item Hamilton Rating Scale for Depression, administered at entry and exit from each treatment level through telephone interviews by assessors masked to treatment assignments. Secondary outcomes include self-reported depressive symptoms, physical and mental function, side-effect burden, client satisfaction, and health care utilization and cost. Participants with an adequate symptomatic response may enter the 12-month naturalistic follow-up phase with brief monthly and more complete quarterly assessments.
authors.affiliation: Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9086, USA. john.rush@utsouthwestern.edu
authors.forename: A John
authors.initials: AJ
authors.lastname: Rush
authors.forename: Maurizio
authors.initials: M
authors.lastname: Fava
authors.forename: Stephen R
authors.initials: SR
authors.lastname: Wisniewski
authors.forename: Philip W
authors.initials: PW
authors.lastname: Lavori
authors.forename: Madhukar H
authors.initials: MH
authors.lastname: Trivedi
authors.forename: Harold A
authors.initials: HA
authors.lastname: Sackeim
authors.forename: Michael E
authors.initials: ME
authors.lastname: Thase
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Nierenberg
authors.forename: Frederic M
authors.initials: FM
authors.lastname: Quitkin
authors.forename: T Michael
authors.initials: TM
authors.lastname: Kashner
authors.forename: David J
authors.initials: DJ
authors.lastname: Kupfer
authors.forename: Jerrold F
authors.initials: JF
authors.lastname: Rosenbaum
authors.forename: Jonathan
authors.initials: J
authors.lastname: Alpert
authors.forename: Jonathan W
authors.initials: JW
authors.lastname: Stewart
authors.forename: Patrick J
authors.initials: PJ
authors.lastname: McGrath
authors.forename: Melanie M
authors.initials: MM
authors.lastname: Biggs
authors.forename: Kathy
authors.initials: K
authors.lastname: Shores-Wilson
authors.forename: Barry D
authors.initials: BD
authors.lastname: Lebowitz
authors.forename: Louise
authors.initials: L
authors.lastname: Ritz
authors.forename: George
authors.initials: G
authors.lastname: Niederehe
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000928:Antidepressive Agents / Q000627:therapeutic use*; D002908:Chronic Disease; D015283:Citalopram / Q000627:therapeutic use; D002985:Clinical Protocols; D015928:Cognitive Behavioral Therapy; D003865:Major Depressive Disorder / Q000188:drug therapy / Q000628:therapy*; D004359:Drug Therapy, Combination; D006801:Humans; D008875:Middle Aged; D011446:Prospective Studies; D011569:Psychiatric Status Rating Scales; D012107:Research Design; D018401:Sample Size; D017367:Selective Serotonin Reuptake Inhibitors / Q000627:therapeutic use
chemical_list: D000928:Antidepressive Agents; D015283:Citalopram; D017367:Selective Serotonin Reuptake Inhibitors