title: Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report.
abstract: OBJECTIVE
  This report describes the participants and compares the acute and longer-term treatment outcomes associated with each of four successive steps in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial.
  
  
  METHODS
  A broadly representative adult outpatient sample with nonpsychotic major depressive disorder received one (N=3,671) to four (N=123) successive acute treatment steps. Those not achieving remission with or unable to tolerate a treatment step were encouraged to move to the next step. Those with an acceptable benefit, preferably symptom remission, from any particular step could enter a 12-month naturalistic follow-up phase. A score of <or=5 on the Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR(16)) (equivalent to <or=7 on the 17-item Hamilton Rating Scale for Depression [HRSD(17)]) defined remission; a QIDS-SR(16) total score of >or=11 (HRSD(17)>or=14) defined relapse.
  
  
  RESULTS
  The QIDS-SR(16) remission rates were 36.8%, 30.6%, 13.7%, and 13.0% for the first, second, third, and fourth acute treatment steps, respectively. The overall cumulative remission rate was 67%. Overall, those who required more treatment steps had higher relapse rates during the naturalistic follow-up phase. In addition, lower relapse rates were found among participants who were in remission at follow-up entry than for those who were not after the first three treatment steps.
  
  
  CONCLUSIONS
  When more treatment steps are required, lower acute remission rates (especially in the third and fourth treatment steps) and higher relapse rates during the follow-up phase are to be expected. Studies to identify the best multistep treatment sequences for individual patients and the development of more broadly effective treatments are needed.
authors.affiliation: Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd., Dallas, TX 75390-9086, USA. john.rush@utsouthwestern.edu
authors.forename: A John
authors.initials: AJ
authors.lastname: Rush
authors.forename: Madhukar H
authors.initials: MH
authors.lastname: Trivedi
authors.forename: Stephen R
authors.initials: SR
authors.lastname: Wisniewski
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Nierenberg
authors.forename: Jonathan W
authors.initials: JW
authors.lastname: Stewart
authors.forename: Diane
authors.initials: D
authors.lastname: Warden
authors.forename: George
authors.initials: G
authors.lastname: Niederehe
authors.forename: Michael E
authors.initials: ME
authors.lastname: Thase
authors.forename: Philip W
authors.initials: PW
authors.lastname: Lavori
authors.forename: Barry D
authors.initials: BD
authors.lastname: Lebowitz
authors.forename: Patrick J
authors.initials: PJ
authors.lastname: McGrath
authors.forename: Jerrold F
authors.initials: JF
authors.lastname: Rosenbaum
authors.forename: Harold A
authors.initials: HA
authors.lastname: Sackeim
authors.forename: David J
authors.initials: DJ
authors.lastname: Kupfer
authors.forename: James
authors.initials: J
authors.lastname: Luther
authors.forename: Maurizio
authors.initials: M
authors.lastname: Fava
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000553:Ambulatory Care; D000928:Antidepressive Agents / Q000627:therapeutic use; D002985:Clinical Protocols; D015928:Cognitive Behavioral Therapy; D003131:Combined Modality Therapy; D003865:Major Depressive Disorder / Q000188:drug therapy / Q000523:psychology / Q000628:therapy*; D004359:Drug Therapy, Combination; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010555:Personality Inventory; D011569:Psychiatric Status Rating Scales; D055502:Secondary Prevention; D011795:Surveys and Questionnaires; D016896:Treatment Outcome
chemical_list: D000928:Antidepressive Agents