Posted by Larry Hoover on January 5, 2008, at 13:31:01
In reply to Re: STAR*D confirmed what patients already knew » Cecilia, posted by linkadge on January 5, 2008, at 11:00:50
> They probably had tried many of these drugs before which begs the question as to why they got better this time. The possible reason being the quality of care they got from this study, which is another reason a placebo seems crucial IMO.
>
> LinkadgeThe methodology could not include placebo. It is an ecological study. Has your doctor ever offered you a placebo? Do you consider placebo treatment to be a common clinical practise?
The study rationale and design is fully discussed in this paper: "Sequenced treatment alternatives to relieve depression (STAR*D): rationale and design." Unfortunately, full text is only available to subscribers. I'd love to read it, if anyone could send me a copy.
The methodology was not designed to show what works. It was designed to deal with non-responders. How do you treat people who fail with the most popular treatment option (i.e. citalopram)? Subjects were allowed to choose e.g. augmentation, but they didn't know which augment they'd receive. If that failed, they could choose a complete change in meds, but again not knowing which they might receive. I don't think placebo would have told us anything about how to treat the non-responders to Level 1 treatment. (Particularly, if one holds the view that antidepressant response *is* placebo response.)
The real meat of the study, IMHO, was the collection of all the patient histories, which can then be correlated to treatment options. Some of the variables considered are: "1) demographic features (e.g., age, race, ethnicity, and gender), 2) social features (e.g., education, employment status, income, insurance, and marital status), and 3) clinical features (e.g., age at onset of major depressive disorder, length of the current major depressive episode, number of major depressive episodes, length of illness, course of illness [single or recurrent], major depressive disorder subtype [anxious, melancholic, and atypical features], family history of depression, concurrent general medical and axis I psychiatric disorders, symptom severity, and functional status at baseline)." These variables may go some way to predicting responsivity, something that the artificial construct of a placebo-controlled efficacy trial can never show.
There are more than eighty papers on Pubmed referencing STAR*D, many of which take a look at one or more of these demographic, social, or clinical features.
Lar
poster:Larry Hoover
thread:804126
URL: http://www.dr-bob.org/babble/20080105/msgs/804449.html