No treatment difference between some antidepressants and CBT for severe depression

The available evidence suggests no difference in treatment effects of second generation antidepressants and cognitive behavioral therapy (CBT) either alone or in combination, for patients with major depressive disorder, finds a study in The BMJ today.

CBT is a type of psychological support that works to solve problems and change unhelpful thinking and behaviour.

Given that patients may have personal preferences for one first line treatment over the other, the researchers say both treatments "should be made accessible, either alone or in combination, to primary care patients with major depressive disorder."

Major depressive disorder is the most common and disabling form of depression, affecting more than 32 million Americans. Treatment is often started in a primary care setting, usually with second generation antidepressant drugs such as SSRIs.

Some research suggests that patients might prefer treatment with psychotherapy over medication, but evidence about which treatments are most effective is unclear.

So, a team led by Gerald Gartlehner at Danube University, supported by Halle Amick and colleagues at the University of North Carolina and the Research Triangle Institute International, analysed the results of 11 randomised controlled trials.

Each trial compared second generation antidepressants and CBT for the initial treatment of major depressive disorder and involved a total of 1,511 patients.

Differences in study design and quality were taken into account to minimise bias.

The team found no statistically significant difference in effectiveness between second generation antidepressants and CBT for response, remission, or change in depression score. Similarly, no significant differences were found in rates of overall study discontinuation or discontinuation due to lack of effectiveness.

No conclusions could be drawn about other outcomes because of lack of evidence, and the researchers stress that their results "should be interpreted cautiously given the low strength of evidence for most outcomes."

Nevertheless, they say their findings "are relatively consistent with similar meta-analyses" and they recommend that both treatments "should be made accessible, either alone or in combination, to primary care patients with major depressive disorder."

In an accompanying editorial, psychiatrist Mark Sinyor and colleagues at the University of Toronto say both options look equally effective, although evidence is limited.

They advocate for more, high quality research comparing antidepressants with CBT in acute depression. In the meantime, they say policy makers "must acknowledge the World Health Organization's projection that major depressive disorder will be the leading cause of disease burden worldwide by 2030 by taking more meaningful steps towards primary prevention."

They believe these steps should include efforts "to correct social antecedents of major depressive disorder such as poverty and lack of education, along with improved mental health curriculums in schools."

Students could also be taught basic CBT or other interventions such as mindfulness, "with the aim of preventing symptoms rather than relying on treatment once symptoms start," they conclude.