Primary Versus Specialty Care Outcomes for Depressed Outpatients Managed with Measurement-Based Care: Results from STAR*D

Abstract

Identical remission and response rates can be achieved in primary and specialty settings when identical care is provided.

The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Trial: A Review

“…8,9 To that end, a measurement-based care strategy was proposed whereby symptoms and side effects would be rated at each visit and clinicians would receive automated feedback to ensure adequate and safe treatments. 8,9 While such a rigorous care strategy may seem at odds with the STAR*D trial's goal of approximating real-world conditions, particularly in primary care settings where there is significant time pressure, STAR*D investigators argue that integrating some form of management-based care into clinical practice is feasible and ought to be considered if it can be shown to improve outcomes. 8,9 The use of remission as the primary outcome of STAR*D reflects a shift by investigators toward more stringent outcome measures in an attempt to maximize the clinical utility of their results.…”

“…8,9 While such a rigorous care strategy may seem at odds with the STAR*D trial's goal of approximating real-world conditions, particularly in primary care settings where there is significant time pressure, STAR*D investigators argue that integrating some form of management-based care into clinical practice is feasible and ought to be considered if it can be shown to improve outcomes. 8,9 The use of remission as the primary outcome of STAR*D reflects a shift by investigators toward more stringent outcome measures in an attempt to maximize the clinical utility of their results. There is a growing body of literature suggesting remission (the near-absence of depressive symptoms) is a more robust outcome than response (50% reduction in symptoms), the most common primary outcome measure in antidepressant RCTs.…”

Wishing Upon a STAR*D: The Promise of Ideal Depression Care by Primary Care Providers

“…STAR * D clinicians used the clinical information collected at these visits to raise the dosage if needed on the basis of the treatment protocol (6). After the first level of treatment (citalopram only), patients in primary care settings had the same or slightly better rates of depression remission and level of depression severity than those treated in specialty care settings (4). …”

Integrating Depression Care: The Time Has Come

“…Comparable depression outcomes can be achieved in primary care and mental health settings, when patients are appropriately managed with monitoring and treatment adjustments. 3 The Veterans Health Administration (VHA) has been an excellent health care system in which to implement and evaluate new models of integrating depression care. A single payer providing comprehensive medical and mental health services for eligible beneficiaries, a commitment to the parity of mental with medical disorders, an investment in mental health resources, and a nationwide electronic medical record all reduce some of the barriers that commonly exist in other practice settings.…”