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Citalopram-resistant depression: cognitive therapy and medication similarly effective as second line treatments

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Dr Thase

Correspondence to: Dr Thase, University of Pittsburgh Medical Center, 3811 O’Hara Street, Pittsburgh, PA 15213-2593, USA;



Cognitive therapy or pharmacotherapy as second-line for people with citalopram-resistant depression—which is more effective?


304 out-patients with non-psychotic major depressive disorder (clinically established diagnosis verified through DSM-IV criteria) enrolled in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study who did not achieve remission (remission defined as Quick Inventory of Depressive Symptomatology score ⩽5) with first-line citalopram treatment. This analysis included only those people who agreed to be randomised to treatment strategies (augmentations, switches or both) which would allow cognitive therapy to be compared with pharmacotherapy.


Primary care and psychiatric care practice settings across the USA; recruitment July 2001 to April 2004.


Participants who did not achieve remission were randomised to one of seven second-line treatments: ongoing citalopram with sustained-release bupropion, buspirone, or cognitive therapy (augmentation strategies; n = 182); or discontinuing citalopram and starting therapy with sertraline, sustained-release bupropion, extended-release venlafaxine, …

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  • web only notes 11/2/48

    As a result of the small number of participants in arms that allowed comparison of cognitive therapy with pharmacotherapy, the study has reduced power. Authors� post hoc power calculation suggests the study had power to detect only large differences between treatments in remission rates (over 20% difference). For the primary outcome, authors used a conservative intention to treat analysis (assumed that people with missing HAM-D scores did not achieve remission). The study did not provide a comparison between augmentation and switch strategies. The design of the STAR*D study may have led to bias in the participating sample, as the proportion of people who accepted psychotherapy was lower than expected.

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