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Predictive Value of Clinical, Demographic, or First-Step Treatment Features

A. John Rush, MD; Stephen R. Wisniewski, PhD; Diane Warden, PhD, MBA; James F. Luther, MA; Lori L. Davis, MD; Maurizio Fava, MD; Andrew A. Nierenberg, MD; Madhukar H. Trivedi, MD

Arch Gen Psychiatry. 2008;65(8):870-880.

Context  Little is known about selecting among second-step medications for major depressive disorder after intolerance or lack of remission with an initial selective serotonin reuptake inhibitor.

Objective  To determine whether sociodemographic, clinical, or first-step treatment features predict remission with or intolerance overall or differentially to any 1 of 3 second-step medications after an unsatisfactory outcome with citalopram hydrobromide.

Design  An equipoise stratified randomized study. Participants were recruited from July 17, 2001, through April 20, 2004.

Setting  Public or private sector primary care (n = 18) and psychiatric care (n = 23) settings across the United States.

Participants  Representative outpatients aged 18 to 75 years with nonpsychotic major depressive disorder (N = 727).

Interventions  Sustained-release bupropion hydrochloride was started at 150 mg/d and incrementally increased to 400 mg/d. Sertraline hydrochloride was started at 50 mg/d and incrementally increased to 200 mg/d. Extended-release venlafaxine hydrochloride was started at 37.5 mg/d and incrementally increased to 375 mg/d.

Main Outcome Measures  The 16-item Quick Inventory of Depressive Symptomatology, Self-Rated and the Frequency, Intensity, and Burden of Side Effects Rating.

Results  Remission was more likely among participants who were white, employed, cohabiting or married, or privately insured or who had prior intolerance to citalopram or at least a response to citalopram, and no prior suicide attempts. Remission was less likely among participants with concurrent generalized anxiety, obsessive-compulsive, panic, or posttraumatic stress disorders; social phobia; anxious or melancholic features; or more severe depression. Intolerance was less likely for Hispanic participants, but more likely for participants with previous suicide attempts or intolerance to citalopram.

Participants with concurrent substance use were less likely to remit (odds ratio, 0.37) and more likely not to tolerate extended-release venlafaxine. Intolerance to citalopram was associated with intolerance to sertraline (P = .04).

Conclusions  Clinical, demographic, and treatment history were of little value in recommending 1 medication vs another as a second-step treatment for major depressive disorder. Participants most likely to remit in the second step had less Axis I psychiatric disorder comorbidity, less social disadvantage, and at least a response to citalopram in the first step.

Trial Registration  clinicaltrials.gov Identifier: NCT00021528

Author Affiliations: Departments of Psychiatry (Drs Rush, Warden, and Trivedi) and Clinical Sciences (Dr Rush), University of Texas Southwestern Medical Center at Dallas; Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Wisniewski and Mr Luther); Department of Psychiatry, University of Alabama School of Medicine, Birmingham, and Veterans' Affairs Medical Center, Tuscaloosa, Alabama (Dr Davis); and Depression Clinical and Research Program, Massachusetts General Hospital, Boston (Drs Fava and Nierenberg).

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