Because the first results from STAR*D make antidepressants look less powerful than we might have hoped, researchers have emphasized another aspect of the study – namely, that it represents a system that allows us to bring research techniques into our practices. And while some statements made in support of the STAR*D methodology come across as pretty grandiose – for example, “This measurement-based care approach represents a paradigm shift to the use of easily employed research tools in clinical practice” (Am J Psychiatry 2006;163:28-40, p 35) – in fact, a review of the STAR*D treatment manual is a useful exercise.
The idea behind the STAR*D protocol is that you score the patient at every visit, and, based on the score, you decide whether or not to increase the dose. Granted, this is what we all try to do daily, but in the course of a busy clinical practice we may not always be as careful and systematic as we’d like. One of the two depression scales used in STAR*D, the QIDS (Quick Inventory of Depressive Symptomatology) is a scale that you can use in your office to ensure that your follow-up depression evaluations are systematic. It is available free of charge from the STAR*D website (www.star-d.org, “clinician resources/assessment tools”). It comes in two versions, a clinician report and a patient self-report.
STAR*D researchers used the results of both QIDS scales to make dosing decisions according to a specific dosing protocol. At each decision point, researchers increased the dose if patients were not in remission; otherwise, the dose remained the same. This protocol, also available on the study’s website, is nice to have as a reference in your office. These guidelines are pretty aggressive, but not unreasonable, and will serve to encourage you to get those doses up to a good level.