title: Efficacy versus effectiveness: a direct comparison of the outcome of treatment for mild to moderate depression in randomized controlled trials and daily practice.
abstract: BACKGROUND
  Results from randomized controlled trials (RCTs) are considered to give the most reliable information on treatment outcome (efficacy). Yet, the generalizability of efficacy results to daily practice (effectiveness) might be diminished by the design of RCTs. The STAR*D trial approached daily practice as much as possible, but still has some properties of an RCT. In this study, we compare results from treatment of major depressive disorder (MDD) in routine clinical practice to those of RCTs and STAR*D.
  
  
  METHODS
  Effectiveness in routine clinical practice was compared with efficacy results from 15 meta-analyses on antidepressant, psychotherapeutic and combination treatment and results from STAR*D. Data on daily practice patients and treatments were derived from a routine outcome monitoring (ROM) system. Treatment outcome was defined as proportion of remitters (MADRS ≤10) and within-group effect size.
  
  
  RESULTS
  From ROM, 598 patients suffering from a MDD episode according to the MINI-plus were included. Remission percentages were lower in routine practice than in meta-analyses for all treatment modalities (32 vs.40-74%). Differences were less explicit for antidepressants (21 vs. 34-47%) than for individual psychotherapy (27 vs. 34-58%; effect size 0.85 vs. 1.71) and combination therapy (21 vs. 45-63%), since only 60% of the meta-analyses for antidepressants showed significant differences with ROM, while for psychotherapy and combination treatment almost all meta-analyses showed significant differences. No differences in effectiveness were found between routine practice and STAR*D (antidepressants 27 vs. 28%; individual psychotherapy 27 vs. 25%; combination treatment 21 vs. 23%, respectively).
  
  
  CONCLUSIONS
  Effectiveness of treatment for mild-to-moderate MDD in daily practice is similar to STAR*D and significantly lower than efficacy results from RCTs.
authors.affiliation: Department of Psychiatry, Leiden University Medical Center/Rivierduinen, Leiden, The Netherlands. r.van_der_lem@lumc.nl
authors.forename: Rosalind
authors.initials: R
authors.lastname: van der Lem
authors.forename: Nic J A
authors.initials: NJ
authors.lastname: van der Wee
authors.forename: Tineke
authors.initials: T
authors.lastname: van Veen
authors.forename: Frans G
authors.initials: FG
authors.lastname: Zitman
mesh_terms: D000328:Adult; D000553:Ambulatory Care / Q000379:methods / Q000706:statistics & numerical data*; D000928:Antidepressive Agents / Q000627:therapeutic use*; D003131:Combined Modality Therapy; D003865:Major Depressive Disorder / Q000628:therapy*; D019317:Evidence-Based Medicine; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D059012:Lost to Follow-Up; D008297:Male; D015201:Meta-Analysis as Topic; D008875:Middle Aged; D009426:Netherlands; D017063:Outcome Assessment, Health Care / Q000379:methods / Q000706:statistics & numerical data*; D010349:Patient Compliance; D018579:Patient Selection; D011613:Psychotherapy; D016032:Randomized Controlled Trials as Topic; D012720:Severity of Illness Index; D016896:Treatment Outcome
chemical_list: D000928:Antidepressive Agents