STAR*D Depression Study Finds Cognitive Therapy Equivalent To Medication But Selected By Fewer Patients

Main Category: Depression
Also Included In: Psychology / Psychiatry
Article Date: 01 May 2007 - 10:00 PDT

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In the federally funded Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, outcomes for cognitive therapy as a second-step treatment were not different from outcomes of medication therapy. However, random assignment in this STAR*D level was based on each patient's treatment preferences, and only 26 percent of the patients accepted cognitive therapy as an option. These findings are reported in two articles in the May issue of The American Journal of Psychiatry (AJP), the official journal of the American Psychiatric Association (APA).

The treatment results are presented in "Cognitive Therapy as a Second-Step Treatment: A STAR*D Report," by Michael E. Thase, M.D., of the University of Pittsburgh, and other STAR*D investigators. The patients in the second treatment step had discontinued citalopram in the first treatment phase, either because it was not effective for them or because the side effects were too burdensome.

In the second step, 36 patients were switched from citalopram to cognitive therapy and 65 received cognitive therapy in addition to citalopram. The first group was compared with patients switched from citalopram to another medication, and the second group was compared with participants receiving citalopram plus a second medication.

The rates of remission over 12 weeks were 25 percent for the patients who switched to cognitive therapy and 23 percent for those who received it as augmentation. These rates were not significantly different from those for the comparison groups assigned to medication. Cognitive therapy produced remission more slowly than medication, but it produced fewer side effects.

Patients' preferences for the second treatment step in STAR*D are examined in "Which Second Step Treatments Are Acceptable to Depressed Outpatients? A STAR*D Report," by Stephen R. Wisniewski, Ph.D., of the University of Pittsburgh, and other STAR*D investigators. Patients were asked which treatments they found acceptable after the initial citalopram trial and whether they had a preference regarding a switch to a new treatment or augmentation of citalopram with another treatment. Patients' preferred treatments were considered in the random assignment of patients to the different treatment conditions.

Of the 1,439 participants who entered second-step treatment, only one percent accepted all treatment options. The 26 percent who accepted cognitive therapy were found to have more education and to be more likely to have a family history of mood disorder than patients who did not include cognitive therapy among their possible treatments. Patients with panic disorder were less likely to accept cognitive therapy. A switch from citalopram to a new treatment, rather than augmentation, was more likely to be accepted by participants in a primary care setting. Cognitive therapy was also less likely to accepted by patients with greater side effects or less reduction in depressive symptoms in the first treatment step. Those with concurrent drug abuse or recurrent depression were less likely to accept a switch strategy.

These findings are discussed in an editorial by Myrna Weissman, Ph.D., of Columbia University.

AJP Editor in Chief Robert Freedman, M.D., stated, "The lower rate of selection of cognitive therapy, despite its effectiveness and freedom from side effects, suggests that rapid, convenient treatment was foremost on patients' minds. Re-thinking psychotherapy to provide more assurance of early effect may improve its appeal to depressed people."

The STAR*D study was funded by the National Institute of Mental Health. Medications were provided at no cost by Bristol-Myers Squibb, Forest Pharmaceuticals, GlaxoSmithKline, King Pharmaceuticals, Organon, Pfizer and Wyeth Pharmaceuticals. Additional financial disclosures appear at the end of the article.

(Am J Psychiatry 2007; 164:790-799; 800-804)

About the American Journal of Psychiatry

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