Primary versus specialty care outcomes for depressed outpatients managed with measurement-based care: results from STAR*D.
BACKGROUND
Whether the acute outcomes of major depressive disorder (MDD) treated in primary (PC) or specialty care (SC) settings are different is unknown.


OBJECTIVE
To compare the treatment and outcomes for depressed outpatients treated in primary versus specialty settings with citalopram in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study (www.star-d.org), a broadly inclusive effectiveness trial.


METHODS
Open clinical trial with citalopram for up to 14 weeks at 18 primary and 23 specialty sites. Participants received measurement-based care with 5 recommended treatment visits, manualized pharmacotherapy, ongoing support and guidance by a clinical research coordinator, the use of structured evaluation of depressive symptoms and side effects at each visit, and a centralized treatment monitoring and feedback system.


METHODS
A total of 2,876 previously established outpatients in primary (n = 1091) or specialty (n = 1785) with nonpsychotic depression who had at least 1 post-baseline measure.


RESULTS
Remission (Hamilton Depression Rating Scale for Depression [Hamilton] or 16-item Quick Inventory of Depressive Symptomatology-Self-Rated [QIDS-SR(16)]); response (QIDS-SR(16)); time to first remission (QIDS-SR(16)). Remission rates by Hamilton (26.6% PC vs 28.0% SC, p = .40) and by QIDS-SR(16) (32.5% PC vs 33.1% SC, p = .78) and response rates by QIDS-SR(16) (45.7% PC vs 47.6% SC, p = .33) were not different. For those who reached remission or response at exit, the time to remission (6.2 weeks PC vs 6.9 weeks SC, p = .12) and to response (5.5 weeks PC vs 5.4 weeks SC, p = .97) did not differ by setting.


CONCLUSIONS
Identical remission and response rates can be achieved in primary and specialty settings when identical care is provided.
Gaynes
Bradley N
BN
Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, NC, USA. bngaynes@med.unc.edu
Rush
A John
AJ
Trivedi
Madhukar H
MH
Wisniewski
Stephen R
SR
Balasubramani
G K
GK
McGrath
Patrick J
PJ
Thase
Michael E
ME
Klinkman
Michael
M
Nierenberg
Andrew A
AA
Yates
William R
WR
Fava
Maurizio
M
D000328:Adult; D000928:Antidepressive Agents / Q000627:therapeutic use*; D015283:Citalopram / Q000627:therapeutic use; D003865:Major Depressive Disorder / Q000188:drug therapy*; D005260:Female; D006801:Humans; D008297:Male; D008511:Medicine; D008605:Mental Health Services; D008875:Middle Aged; D010045:Outpatients; D011320:Primary Health Care; D011584:Psychology; D017367:Selective Serotonin Reuptake Inhibitors / Q000627:therapeutic use; D013038:Specialization; D016896:Treatment Outcome
D000928:Antidepressive Agents; D015283:Citalopram; D017367:Selective Serotonin Reuptake Inhibitors