Research

Question 1

Star D trial interventions

Answer 1

Step 1: All participants received flexible-dose citalopram. If in remission, enter 12-month naturalistic follow up. If no remission, proceed to step 2.
Step 2: 3 augmentation strategies (citalopram + bupropion; citalopram + buspirone; citalopram + CBT) and 4 switch strategies (buproprion, sertraline, venlafaxine, CBT). If in remission, enter 12-month naturalistic follow up. If no remission, proceed to step 3.
Step 3: 2 augmentation strategies (lithium or triiodothyronine [T3]) and 2 switch strategies (nortriptyline, mirtazapine). If in remission, enter 12-month naturalistic follow up. If no remission, proceed to step 4.
Step 4: randomized to treatment with either tranylcypromine or combination venlafaxine XR and mirtazapine.

Question 2

STAR D trial outcome

Answer 2

A four-step treatment algorithm aiming for depression remission in non-psychotic depressed outpatients resulted in remission rates of 36.8% and 30.6% for first two steps, respectively, with higher relapse rates for individuals requiring the third and fourth treatment steps.

Psychotherapy is a reasonable monotherapy for patients with mild to moderate MDD
Patients with mild, moderate, or severe MDD can be treated with antidepressants, findings that would suggest their use as preferred modality include prior response to them, moderate to severe symptoms, significant sleep or appetite disturbances, agitation, preference of the patient, and suspicion for need of maintenance therapy
Suggest combining depression-focused psychotherapy with pharmacotherapy for patients with moderate to severe MDD

Question 3

Star D trial overview

Answer 3

Step 1 was citalopram only. Those with remission were entered into a 12-month follow up protocol. Those who did not attain remission were randomly enrolled in step 2 treatment, which consisted of 7 different treatment options. The equipoise stratified design allowed patients to choose a switch or augmentation strategy for steps 2 and 3.

As expected, remission rates were higher in earlier steps, with step 1 achieving remission in 36.8% of patients. Among the individuals that progressed to step 2, remission was achieved in 30.6%. Steps 3 and 4 achieved remission in 13.7% and 13%, respectively

Question 4

Star D Clinical Question

Answer 4

Among patients with unipolar major depression without psychotic features, how often is remission achieved when using a tiered protocol?

Question 5

CATIE Clinical Question

Answer 5

Among patients with schizophrenia, how do the second-generation antipsychotic medications such as olanzapine, quetiapine, risperione and ziprasidone compare to first-generation antipsychotic medications such as perphenazine in terms of relative effectiveness?

Question 6

CATIE outcome

Answer 6

The primary outcome was time to discontinuation for any cause, and remarkably, only 26% of patients completed 18 months of the study drug to which they were randomized. Olanzapine was associated with a longer time to discontinuation than quetiapine or risperidone, but was similar to perphenazine and ziprasidone. Olanzapine was associated with greater weight gain, hyperlipidemia, and hyperglycemia, whereas ziprasidone was associated with weight loss and improvement in lipids and in blood glucose.

Question 7

STEP BD research question

Answer 7

Among patients with bipolar disorder receiving mood stabilizing agents, does adjunctive antidepressant therapy reduce the symptoms of dipolar disorder without increasing mania?