What if STAR*D Had Been Placebo-Controlled? A Critical Reexamination of a Foundational Study in Depression Treatment

The STAR*D trial's sequence of dose escalation, switching, and augmentation strategies has served as a model for most depression treatment guidelines. However, STAR*D was an open-label pragmatic trial that did not use a placebo control, which complicates the assessment of its outcomes. Most STAR*D treatment steps have now been studied in blinded placebo-controlled randomized trials, which could validate STAR*D and support the growing use of pragmatic trials in depression.

This review evaluates outcomes from randomized controlled trials (RCTs) for the major STAR*D treatment steps: dose increase after inadequate response to an antidepressant (Level 1), switching the antidepressant after treatment nonresponse (Levels 2 and 3), augmenting an antidepressant with bupropion or buspirone (Level 2), augmenting an antidepressant with lithium or T3 thyroid hormone (Level 3), and using combination mirtazapine-venlafaxine (Level 4).

RCTs have generally not replicated the findings of STAR*D. Of the major treatment steps, there is only positive evidence for lithium augmentation and α2-antagonist-serotonin-reuptake inhibitor combination. Limitations of this review include variation in the quality and quantity of comparable RCTs for each treatment level and differences in the inclusion criteria of RCTs and STAR*D.

These findings raise questions about the evidence supporting widely used treatment strategies following an inadequate response to an initial antidepressant. They suggest that pragmatic trials should be interpreted cautiously in the absence of blinded placebo-controlled studies and point to the need for high-quality blinded clinical trials of second-step and third-step depression treatments.