Cognitive therapy versus medication in augmentation and switch strategies as second-step treatments: a STAR*D report.
OBJECTIVE
The authors compared the effectiveness of cognitive therapy and pharmacotherapy as second-step strategies for outpatients with major depressive disorder who had received inadequate benefit from an initial trial of citalopram. Cognitive therapy was compared with medication augmentation and switch strategies.


METHODS
An equipoise-stratified randomization strategy was used to assign participants to either augmentation of citalopram with cognitive therapy (N=65) or medication (N=117; either sustained-release bupropion [N=56] or buspirone [N=61]) or switch to cognitive therapy (N=36) or another antidepressant (N=86; sertraline [N=27], sustained-release bupropion [N=28], or extended-release venlafaxine [N=31]). Treatment outcomes and the frequency of adverse events were compared.


RESULTS
Less than one-third of participants consented to randomization strata that permitted comparison of cognitive therapy and pharmacotherapy. Among participants who were assigned to second-step treatment, those who received cognitive therapy (either alone or in combination with citalopram) had similar response and remission rates to those assigned to medication strategies. For those who continued on citalopram, medication augmentation resulted in significantly more rapid remission than augmentation with cognitive therapy. Among those who discontinued citalopram, there were no significant differences in outcome, although those who switched to a different antidepressant reported significantly more side effects than those who received cognitive therapy alone.


CONCLUSIONS
After an unsatisfactory response to citalopram, patients who consented to random assignment to either cognitive therapy or alternative pharmacologic strategies had generally comparable outcomes. Pharmacologic augmentation was more rapidly effective than cognitive therapy augmentation of citalopram, whereas switching to cognitive therapy was better tolerated than switching to a different antidepressant.
Thase
Michael E
ME
Department of Psychiatry, University of Pittsburgh Medical Center, 3811 OHara St., Pittsburgh, PA 15213-2593, and Massachusetts General Hospital, USA. thaseme@upmc.edu
Friedman
Edward S
ES
Biggs
Melanie M
MM
Wisniewski
Stephen R
SR
Trivedi
Madhukar H
MH
Luther
James F
JF
Fava
Maurizio
M
Nierenberg
Andrew A
AA
McGrath
Patrick J
PJ
Warden
Diane
D
Niederehe
George
G
Hollon
Steven D
SD
Rush
A John
AJ
D000328:Adult; D000553:Ambulatory Care; D000928:Antidepressive Agents / Q000627:therapeutic use; D016642:Bupropion / Q000627:therapeutic use; D002065:Buspirone / Q000627:therapeutic use; D015283:Citalopram / Q000627:therapeutic use*; D015928:Cognitive Behavioral Therapy; D003131:Combined Modality Therapy; D018592:Cross-Over Studies; D003511:Cyclohexanols / Q000627:therapeutic use; D003663:Decision Trees; D003692:Delayed-Action Preparations; D003865:Major Depressive Disorder / Q000523:psychology / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D017366:Serotonin Receptor Agonists / Q000627:therapeutic use; D017367:Selective Serotonin Reuptake Inhibitors / Q000627:therapeutic use*; D016896:Treatment Outcome; D000069470:Venlafaxine Hydrochloride
D000928:Antidepressive Agents; D016642:Bupropion; D002065:Buspirone; D015283:Citalopram; D003511:Cyclohexanols; D003692:Delayed-Action Preparations; D017366:Serotonin Receptor Agonists; D017367:Selective Serotonin Reuptake Inhibitors; D000069470:Venlafaxine Hydrochloride