What did the STAR*D trial reveal about depression treatment effectiveness?
A commentary in Psychiatric Services by Insel and Wang, writing from the National Institute of Mental Health, reports STAR*D remission rates of 28% after initial treatment and 70% at one year, and argues that the bar for antidepressants has been set far too low. This is an editorial appraisal of the trial rather than a new trial of its own.
The authors call STAR*D a landmark study that continues to stimulate debate, and they conclude that important goals for treating this disabling disease remain out of reach.
What the commentary reports:
- Initial remission: 28%
- One-year remission: 70%
- Design precedent: STAR*D demonstrated the feasibility of large-scale, community-based studies conducted without pharmaceutical company support
- Clinical insight: the results informed understanding of nonresponse to initial treatment with selective serotonin reuptake inhibitors, and of second- and third-line options
- Direction of travel: the findings suggested opportunities for personalized approaches to depression care
The authors’ reading is that these remission figures reveal the need for better treatments, not that the trial settled the question of how depression should be treated.
Dr. Kumar’s Take
STAR*D is still the reference point I return to when a patient asks what the odds are with a first antidepressant. Twenty-eight percent remission on the initial treatment is a sobering number to sit with in clinic, and it reframes a failed first medication as an expected step rather than a personal failure. The seventy percent figure at one year is the other half of the picture, and I think both belong in the conversation. Insel and Wang’s argument is that a treatment standard which produces those numbers has set the bar too low, and I agree with that framing. The trial’s real contribution to my practice is not a single statistic but the case it makes for matching treatment to the individual patient instead of running everyone through the same sequence.
What the Research Shows
The commentary treats STAR*D as a landmark trial that continues to stimulate debate rather than as a closed chapter. Its authors credit the study with demonstrating something the field needed: that a large-scale, community-based treatment study could be run without pharmaceutical company support.
Beyond the design precedent, the results gave clinicians insight into what happens when initial treatment with a selective serotonin reuptake inhibitor does not work, and into the alternatives available at the second and third line. The authors also read the data as pointing toward personalized approaches to depression care.
Their conclusion is blunt. Initial and one-year remission rates of 28% and 70% mean that important goals for the treatment of a disabling disease remain out of reach.
Study Snapshot
STAR*D stands for Sequenced Treatment Alternatives to Relieve Depression.
This particular publication is a 2009 commentary in Psychiatric Services from authors at the National Institute of Mental Health, appraising what the trial did and did not accomplish.
Safety, Limits, and Caveats
A commentary is an interpretation, not new data. Insel and Wang are making an argument about what the STAR*D results mean for the field, and they acknowledge that the trial continues to stimulate debate.
Nothing here suggests abandoning antidepressant treatment. The authors’ point is about the standard the field has accepted for what counts as an adequate antidepressant, not about whether individual patients should take one.
Practical Takeaways
- Expect that depression treatment may take more than one attempt, since most patients in STAR*D did not remit on the initial treatment
- Treat a first medication that does not work as information about the illness, not as a personal failure
- Ask your clinician what the second- and third-line options are before you need them, because STAR*D was built to answer exactly that question
- Consider approaches tailored to you rather than a fixed sequence, which is the direction the authors say the results point
- Keep in mind that remission rates improved by one year, so a slow start is not the whole trajectory
What This Means for Depression Treatment
The argument in this commentary is that STAR*D’s numbers should push the field toward better treatments rather than reassure it. If the standard for an approved antidepressant produces the remission rates seen here, the authors say the bar has been set far too low.
The constructive reading is the one they offer alongside the criticism: the trial produced real insight into nonresponse to initial SSRI treatment and into what to try next, and it suggested opportunities for personalized approaches to depression care.
Related Studies and Research
Episode 31: Depression Explained, The Biology Behind the Darkness
Episode 32: Depression Recovery Roadmap: A Step-by-Step, Evidence-Based Plan
FAQs
Does STAR*D mean antidepressants don’t work?
No. The commentary reports that 28% of patients reached remission with initial treatment and 70% at one year, and it argues that these figures show the need for better treatments. That is a statement about the standard of care, not a claim that antidepressants are useless.
What should patients do with STAR*D’s findings?
Plan for the possibility that the first treatment will not produce remission, and discuss second- and third-line options with a clinician. The trial was designed to study exactly those sequential alternatives.
What did STAR*D contribute beyond its remission rates?
It showed that a large-scale, community-based treatment study could be conducted without pharmaceutical company support, and it produced insight into nonresponse to initial SSRI treatment and into personalized approaches to care.
Bottom Line
Insel and Wang report STAR*D remission rates of 28% after initial treatment and 70% at one year, and conclude that important goals for treating depression remain out of reach and that the bar for antidepressants has been set far too low. The trial’s lasting value, in their reading, is the case it builds for better treatments and for personalized approaches to depression care.
