Psychological Medicine

Original Articles

Painful physical symptoms and treatment outcome in major depressive disorder: a STAR*D (Sequenced Treatment Alternatives to Relieve Depression) report

A. F. Leuchtera1 c1, M. M. Husaina2, I. A. Cooka1, M. H. Trivedia2, S. R. Wisniewskia3, W. S. Gilmera4, J. F. Luthera3, M. Favaa5 and A. J. Rusha2

a1 Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

a2 Department of Psychiatry, University of Texas Southwestern Medical School, Dallas, TX, USA

a3 Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA

a4 Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

a5 Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA


Background Painful physical symptoms (PPS) are both common and reduce the likelihood of remission in major depressive disorder (MDD), based upon results of clinical trials in selected populations. Whether PPS significantly contribute to poorer treatment outcome overall in primary or specialty psychiatric care settings remains unclear.

Method Out-patients (n=2876) with MDD were treated in the first step of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial with citalopram up to 60 mg/day for up to 14 weeks. Presence of painful symptoms, as well as severity of depression, physical illness, and demographic and treatment factors were examined. Time to and overall rates of remission were analysed in relation to the presence of PPS.

Results Of the participants, 80% complained of PPS. These patients, both in primary and specialty psychiatric settings, had significantly lower remission rates and took longer to remit. Increasing severity of PPS was associated with greater physical illness burden, lower socio-economic status, absence of private insurance and being female, African-American or Hispanic. After adjustment for these factors, patients with PPS no longer had significantly poorer treatment outcomes.

Conclusions Presence and severity of PPS is an indicator of MDD that may have poorer treatment outcome with an initial selective serotonin reuptake inhibitor. These poorer treatment outcomes are multifactorial, however, and are not explained by the presence and severity of pain per se.

(Received September 27 2008)

(Revised March 31 2009)

(Accepted April 04 2009)

(Online publication June 03 2009)


c1 Address for correspondence: A. F. Leuchter, M.D., Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Laboratory of Brain, Behavior, and Pharmacology, Semel Institute for Neuroscience and Human Behavior at UCLA, 760 Westwood Plaza, Room 37-452, Los Angeles, CA 90024-1759, USA. (Email:

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