title: Acceptability of second-step treatments to depressed outpatients: a STAR*D report.
abstract: 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.
authors.affiliation: 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
authors.forename: Stephen R
authors.initials: SR
authors.lastname: Wisniewski
authors.forename: Maurizio
authors.initials: M
authors.lastname: Fava
authors.forename: Madhukar H
authors.initials: MH
authors.lastname: Trivedi
authors.forename: Michael E
authors.initials: ME
authors.lastname: Thase
authors.forename: Diane
authors.initials: D
authors.lastname: Warden
authors.forename: George
authors.initials: G
authors.lastname: Niederehe
authors.forename: Edward S
authors.initials: ES
authors.lastname: Friedman
authors.forename: Melanie M
authors.initials: MM
authors.lastname: Biggs
authors.forename: Harold A
authors.initials: HA
authors.lastname: Sackeim
authors.forename: Kathy
authors.initials: K
authors.lastname: Shores-Wilson
authors.forename: Patrick J
authors.initials: PJ
authors.lastname: McGrath
authors.forename: Philip W
authors.initials: PW
authors.lastname: Lavori
authors.forename: Sachiko
authors.initials: S
authors.lastname: Miyahara
authors.forename: A John
authors.initials: AJ
authors.lastname: Rush
mesh_terms: 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
chemical_list: D015283:Citalopram; D017367:Selective Serotonin Reuptake Inhibitors