The most recent findings from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial provided little help regarding which medication to prescribe if an initial SSRI trial failed to result in remission of depressive symptoms. Patients who did not show remission after a Celexa (citalopram) trial were assigned to receive Wellbutrin (bupropion), Zoloft (sertraline), or Effexor (venlafaxine). Very few patient characteristics or first-step treatment features were reliably linked to differential response to any of the medica- tions. Patientswithcomorbidgeneralized anxiety, OCD, panic disorder, PTSD, or social phobia were all less likely (some- times to a statistically significant extent) to remit in the second step regardless of the specific medication they received. Anxious features correlated with lower remission rates across all medications. Effexor was associated with a lower chance of remis- sion among patients with a comorbid substance abuse disorder, but given the large number of statistical tests run by the researchers, this could be a chance finding. Unsurprisingly, patients who could not tolerate Celexa in the first step were less likely to tolerate Zoloft (another SSRI) in the second step, compared to Wellbutrin or Effexor (Rush AJ et al., Arch Gen Psychiatry. 2008;65:870-881).

TCPR'S Take: In the second step of treatment, remission rates were relatively low across all medications, ranging from 18%-27% depending on the depression measure. Thesefindingsprovidelittle helpful information for prescribers regard- ing medication selection for depression that is not completely responsive to first- steptreatment. TheJanuary2007issueof TCPR offers additional advice regarding treatment-resistant depression.