Acceptability of second-step treatments to depressed outpatients: a STAR*D report.
OBJECTIVE
Treatment of major depressive disorder typically entails implementing treatments in a stepwise fashion until a satisfactory outcome is achieved. This study sought to identify factors that affect patients' willingness to accept different second-step treatment approaches.


METHODS
Participants in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial who had unsatisfactory outcomes after initial treatment with citalopram were eligible for a randomized second-step treatment trial. An equipoise-stratified design allowed participants to exclude or include specific treatment strategies. Analyses were conducted to identify factors associated with the acceptability of the following second-step treatments: cognitive therapy versus no cognitive therapy, any switch strategy versus any augmentation strategy (including cognitive therapy), and a medication switch strategy only versus a medication augmentation strategy only.


RESULTS
Of the 1,439 participants who entered second-step treatment, 1% accepted all treatment strategies, 3% accepted only cognitive therapy, and 26% accepted cognitive therapy (thus, 71% did not accept cognitive therapy). Those with higher educational levels or a family history of a mood disorder were more likely to accept cognitive therapy. Participants in primary care settings and those who experienced a greater side effect burden or a lower reduction in symptom severity with citalopram were more likely to accept a switch strategy as compared with an augmentation strategy. Those with concurrent drug abuse and recurrent major depressive disorder were less likely to accept a switch strategy.


CONCLUSIONS
Few participants accepted all treatments. Acceptance of cognitive therapy was primarily associated with sociodemographic characteristics, while acceptance of a treatment switch was associated with the results of the initial treatment.
Wisniewski
Stephen R
SR
Department of Psychiatry, Epidemiology Data Center, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, and Clinical Psychopharmacology Unit, Massachusetts General Hospital, Boston, USA. wisniew@edc.pitt.edu
Fava
Maurizio
M
Trivedi
Madhukar H
MH
Thase
Michael E
ME
Warden
Diane
D
Niederehe
George
G
Friedman
Edward S
ES
Biggs
Melanie M
MM
Sackeim
Harold A
HA
Shores-Wilson
Kathy
K
McGrath
Patrick J
PJ
Lavori
Philip W
PW
Miyahara
Sachiko
S
Rush
A John
AJ
D000328:Adult; D000553:Ambulatory Care; D015283:Citalopram / Q000627:therapeutic use*; D002985:Clinical Protocols; D015928:Cognitive Behavioral Therapy; D003131:Combined Modality Therapy; D018592:Cross-Over Studies; D003865:Major Depressive Disorder / Q000188:drug therapy / Q000453:epidemiology* / Q000628:therapy*; D004522:Educational Status; D005260:Female; D006801:Humans; D008297:Male; D010342:Patient Acceptance of Health Care; D011320:Primary Health Care / Q000706:statistics & numerical data; D011446:Prospective Studies; D012008:Recurrence; D017367:Selective Serotonin Reuptake Inhibitors / Q000627:therapeutic use; D012720:Severity of Illness Index; D019966:Substance-Related Disorders / Q000453:epidemiology; D016896:Treatment Outcome
D015283:Citalopram; D017367:Selective Serotonin Reuptake Inhibitors