Antidepressants do work in depression while evidence for CBT is poorer say experts

May 6, 2008

A new revision of clinical guidelines to help doctors manage patients with depression has challenged the rationale behind the UK government’s policy of rolling out of cognitive behavioural therapy (CBT) for milder depression.

According to a comprehensive review of treatments for depression, there is a lack of evidence for CBT being more helpful than other forms of psychological support in mild depression or for its efficacy in severe depression. There is also good evidence for antidepressants being effective in depression, with benefit increasing the more severe the depression. This is contrary to recent reports that antidepressants don’t work except in the most severe depression.

Dr Ian Anderson, Senior Lecturer and Honorary Consultant Psychiatrist, Neuroscience and Psychiatry Unit, University of Manchester, UK, says the cost effectiveness of CBT should be thoroughly investigated before it is adopted more widely because it is likely to be offered to people with milder depression where the evidence is poorest.

“There is often not a level playing field in considering evidence for drugs versus psychological treatment, especially in milder depression,” Dr Anderson explains, adding that specific psychological treatments are relatively expensive compared to drug treatments because treatment involves training of the therapists as well as the costs of administering the intervention.

To measure the effectiveness of these treatments requires “comparison against appropriate control treatment like non-specific supportive treatment in the same way drugs are compared against placebo,” says Dr Anderson. “This is important given the rolling out of CBT for milder depression – probably less expensive means of support are more cost-effective.”

This conclusion is just one of the issues to emerge from a comprehensive review of the evidence for various forms of management of depression, conducted as part of a revision of the 2000 British Association for Psychopharmacology evidence-based guidelines, and published this week by SAGE in the Journal of Psychopharmacology. The aim of the review was to incorporate new evidence and to update the recommendations where appropriate.

Revisions to the guidelines were agreed after a consensus meeting involving experts in depressive disorders and their management, user representatives, and medical and scientific staff from pharmaceutical companies in May 2006 and a subsequent literature review.

The new guidelines also question whether CBT should routinely be combined with antidepressant medication for depression in adolescents—as the UK’s National Institute for Health and Clinical Excellence suggests—citing a lack of evidence. Dr Anderson says some recommendations run contrary to NICE guidance:

-- First, the choice between antidepressants and CBT needs to be individually decided rather than routinely recommending CBT first.

-- Second, combining CBT with antidepressants should not be routine.

He suggests that doctors should try to adopt a more dimensional approach to depression rather than over-emphasising categories of disease severity such as “not depressed”, “clinical depression”, etc, or relying too heavily on cut-off points such as simply counting symptoms. It is important to consider an individual patient’s situation in a more rounded fashion such as past history, degree of impairment, duration of symptoms and risk of relapse.

“Overall, the guidelines clear up some issues and alter the emphasis on certain treatments for example suggesting that for subthreshold depression, which is not of clinical severity, antidepressants should be considered if it lasts more than 2-3 months,” Dr Anderson says. “We have also challenged the idea that antidepressants need to be given more than once a day or that for most antidepressants you need to follow a long tailing off before starting a new antidepressant.”

“We hope [the guidelines] will set a standard. We have tried to be practical in our advice and addressed issues that other guidelines tend not to be specific about such as managing side-effects of antidepressants. We want to help doctors and patients choose treatments and strategies that have the best chance of helping,” Dr Anderson concludes.

Source: SAGE Publications

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not rated yet May 06, 2008
Not sure why the UK mental health professionals are down on CBT. Antidepressants shouldn't be considered permanent treatment approach. They are a bridge to return to emotional wellness.

Physicians should be evaluating antidepressant AND alternative patient training (eg., lifestyle changes to alleviate mostly self-induced dopamine/serotonin inbalances) during treatment. To evaluate efficacy, you need pre-treatment brain scans to set 'baseline' comparator conditions and you need periodic scans to measure drug performance - is it actually changing brain chemistry for the better (rebalancing brain center activity)?? If not, change meds and look more closely at lifestyle issues that maybe countering treatment efficiency (assuming the drugs work in your patient).

Classic example: abuse of 'self-medicants' (eg., stress-reducing alcohol, nicotine, recreational drugs) during teen years predisposes adults to depressive episodes, because of faulty stress tolerance biochemistry, combined with lousy lifestyle choices (poor diet, chronic lack of sleep, insufficient exercise/fresh air and sunlight). When these adults (and more often now, young adults) encounter stressful life conditions, they develop neurological chemistry deficits (affecting coupled cannabinoid and dopamine receptor function). They fail to recover from stressful events and what might be a transient depressive episode for healthy individuals with sound stress tolerance thesholds, becomes chronic depression in the individual who has barebones stress coping capacity before the stressful event(s) occurred.

Few doctors will question patients - are you smoking? Do you abuse alcohol? Do you get quality sleep and is your diet sound? Are you in a difficult personal relationship or is there an outside source of excessive stress? Usually, you are lucky to have your physicians attention for a solid 5 minutes! A nurse practitioner might be a boon in helping patients sort out confounding issues that may slow or block successful depression treatment.

The standard medical pitch is to place patients on antidepressants for the longterm. Rarely do doctors recommend additional behavioral training to help patients regain healthy lifestyle patterns that in time can 'reset' stress tolerance threshold. You can't take patients off of antidepression meds unless you have either (a) addressed the underlying causes or (b) have another drug to bolster neurochemistry deficits. But then, in (b), you are advocating run-on treatment that just may, in the long run, harm more than help the patient, as response to these drugs tends to wane over time. I have spoken to patients who have been on antidepressants for 10-15 years, with little or no hope of recovery.

The comment on relapse is 'spot on' - and here, CBT can be an important counter, as its possible to train patients to use practicable behavioral patterns that alter psychological response to stress, avoiding the pitfall of sinking below stress tolerance thresholds (again) and falling back into a chemical deficit that causes chronic depression.

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