Of the participants who entered STAR*D's second level, 21% indicated that they would accept randomization to either an augmentation therapy or being switched to another treatment. In each category (switch or augmentation) several options were offered for random assignment. The remaining 79% identified which of the offered treatment options were acceptable to them and were randomized to this limited set of treatments. Based on these choices, 51% were randomly assigned to a medication switch, 39% were randomized to an augmentation option, and the remaining 10% were randomized to cognitive therapy (a “switch” condition).
Those switched to a new medication received either sertraline (Zoloft, an SSRI), bupropion-SR (Wellbutrin, a non-SSRI antidepressant), or venlafaxine-XR (Effexor, which targets both serotonin and norepinephrine). Unlike in previous research, no difference in efficacy or tolerability was found between the three medications.
Augmentation medications included bupropion-SR or buspirone (Buspar, an SSRI enhancer). They were similar in effecting remission, but participants augmenting with bupropion-SR reported fewer symptoms, greater symptom relief, and lower side effects.
Similar to the CATIE study, STAR*D participants were able to declare particular treatment options acceptable or not before being randomized to one of several options—supporting the ability to generalize the findings to practice in the field.
The findings of both the CATIE and STAR*D studies provide guidance for treatment in real-world terms and highlight the importance of collaborative work between prescribers and consumers in determining acceptable and effective treatment. In that light, the study findings are more accessible than ever to the spectrum of clinicians working with these illnesses. Similarly, the findings are more useful to consumers seeking relief from the burden of severe mental illness.
The studies' timing couldn't be better given the momentum of public policy favoring parity. Both developments encourage a stronger voice for consumers of mental health services regarding their treatment needs. It's up to us to keep the momentum going.
Sandra Wilkniss, PhD, is the Director of Research at Thresholds, Inc., in Chicago. Thresholds is Illinois' largest psychiatric rehabilitation and recovery agency.
Mark Amdur, MD, is Medical Director at Thresholds, Inc., in Chicago. Thresholds is Illinois' largest psychiatric rehabilitation and recovery agency.
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