The STAR*D trials I: Medication augmentation for depression [Classics Series]

Classics Series, Landmark Trials in Medicine

1. In patients who have not experienced remission of depression despite vigorous treatment with an SSRI, augmentation of treatment by adding buproprion or buspirone can achieve remission in approximately 30% of patients.

2. There were no significant differences between the two groups in terms of remission rates.

Original Date of Publication: March 2006

The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trials explored the management of patients who had refractory depression despite treatment with a selective serotonin-reuptake inhibitor (SSRI). Two papers were published based on data from the STAR*D trials in NEJM in 2006, which involved outpatients with nonpsychotic major depression who had not experienced remission with citalopram alone. In both papers, the primary outcome measure was remission with a score of <7 on the Hamilton Rating Scale for Depression (HRSD-17), while secondary outcome measurement of remission and response was done using the Quick Inventory of Depressive Symptomatology (QIDS-SR-16). Patients in this study were given the option to 1) augment their therapy by adding other agents or 2) switch to another therapy.

Study Rundown: This paper demonstrates that in patients with refractory depression despite vigorous SSRI treatment, augmenting therapy by adding buproprion or buspirone to existing SSRI therapy can help achieve remission in approximately 30% of patients. While there were no significant differences between the buproprion and buspirone groups in terms of remission rates, patients in the buproprion group were adherent to treatment for significantly longer periods of time, and experienced higher reductions in QIDS-SR-16 scores.

Click to read study in NEJM

In-Depth [randomized, controlled trial]: The use of medications to augment SSRI therapy is common practice in the treatment of depression, though no previous randomized controlled trials had explored this issue. A total of 565 patients were recruited and randomized to either receive 1) sustained-release buproprion or 2) buspirone, in addition to citalopram, an SSRI.

There were no significant differences in remission rates between the two groups based on HSRD-17 scores (29.7% for buproprion group, 30.1% for buspirone group). Similarly, remission and response rates based on QIDS-SR-16 scores were not significantly different between the two groups. Patients in the buproprion group were adherent to treatment for significantly longer than those in the buspirone group (10.2 weeks vs. 9.2 weeks, P=0.01). Moreover, patients in the buproprion group experienced significantly higher reductions in QIDS-SR-16 scores at the end of the study when compared to the buspirone group.

Image: PD

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