Trying to find evidence to guide practice in mental health can be perplexing at the best of times. Take antidepressants for example: seemingly prescribed by the bucketload (170 million prescriptions issued per year in the US, 31 million in the UK) many GPs and psychiatrists will admit that when it comes to choice of drug, more often than not it’s a case of ‘suck it and see’. We may have a raft of sophisticated neuroimaging techniques but we still struggle to explain how they work and when it comes to predicting response – well that’s anybody’s guess.
These days, we view pharma-funded trials with a jaundiced eye, particularly when they are promoted by ‘key opinion leaders’ (to see one KOI meet his nemesis, take a look at the Carlat Psychiatry Blog), so I would recommend this month’s Editor’s Choice (that means it’s free to access) in Evidence-Based Mental Health. Simon Hatcher casts a critical gaze over the STAR*D trial, the largest study of treatments for depression ever undertaken. It is one of the new breed of pragmatic trials – studies that assign ‘real world’ patients to licensed drugs aiming to assess their effectiveness (do they work in real life?) rather than efficacy (do they work in ideal conditions?). Publicly funded, at a cost of $35 million, and enrolling almost 3000 participants STAR*D really is, as Hatcher states, the 300lb gorilla of antidepressant trials. So what does STAR*D tell us? Well, read the review to find out but it’s clear that quality is just as important as quantity.