Severe depression shouldn't rule out first-line cognitive behavioral therapy

By Larry Hand

Despite guidelines calling for first-line pharmacotherapy for severe depression, a new study found that baseline depression severity does not moderate outcomes between pharmacotherapy and cognitive therapy.

"That means that patients with more severe depression are no more likely to require medications to improve than patients with less severe depression," Dr. Pim Cuijpers, professor and head of clinical, neuro-, and developmental psychology at VU University Amsterdam, the Netherlands, told Reuters Health by email.

"Currently treatment guidelines suggest that when depression is severe, pharmacotherapy should be the first-line of treatment. However, the current study does not provide evidence to support this," he explained.

Dr. Cuijpers and colleagues conducted an unconventional meta-analysis of randomized clinical trials comparing outcomes between cognitive behavioral therapy (CBT) and antidepressants in patients with confirmed depression.

In addition to a normal meta-analysis, they used independent patient data meta-analysis (IPDMA), "a new technique in the mental health field, but it has been used successfully to examine acute and preventive treatments in medicine," they wrote online September 23 in JAMA Psychiatry.

A literature search turned up 14,902 abstracts for initial review, from which they chose 1613 for full-text review. From those they chose "for various reasons" 24 studies for inclusion in their IPDMA, accounting for 1700 outpatients. The studies originated in the U.S., Canada, Germany, Romania, and Iran.

They invited authors of the 24 studies to participate in the IPDMA and contribute original patient data, and authors of 16 of the 24 studies complied. However, the researchers found no significant difference in effect sizes between studies with provided data and studies without provided data.

Patients had a mean age of 37, 69% were female, and 90% had a high school education. About half had severe depression at baseline.

Medical therapy consisted of selective serotonin reuptake inhibitors in nine studies, tricyclic antidepressants in four, and other antidepressants in three. CBT was delivered individually in 14 studies, in a group in two, and both ways in one, with the number of sessions ranging from eight to 28.

The researchers analyzed outcomes using the 17-item Hamilton Rating Scale for Depression (HAM-D) and Beck Depression Inventory (BDI). Ten of 16 studies had both scores.

They found no significant differences between pharmacotherapy and cognitive therapy regarding the outcomes of response and remission. Responses were seen in 63% of pharmacotherapy patients and 58% of CBT patients. Roughly half of each group met remission criteria.

There was a significant main effect of pharmacotherapy over CBT on HAM-D scores (<1, p=0.03), but no evidence of interaction, and a nonsignificant trend in BDI scores. Both scoring methods have been criticized, they wrote, but are widely used measures.

"In this IPDMA, we found no evidence that baseline severity of depression, whether patient or clinician rated, moderated the effect of treatment outcomes. That is, patients with more severe depression were no more likely to require medications to improve than patients with less severe depression, and these findings were robust in sensitivity analyses," the researchers wrote.

The authors caution that these results might not generalize to other psychotherapies or to combination therapies.

"More research is needed on identifying which patients (with which specific characteristics) benefit from which treatments," Dr. Cuijpers said. "Current research states that there is none to small differences in effectiveness between treatments (psychological and pharmacological). However, we do not yet know which patients fare better in which treatments."

He concluded, "The central message is that in contrast to what treatment guidelines say, baseline severity does not moderate the outcome of (cognitive therapy) and medication for adult depression."

SOURCE: http://bit.ly/1WixvcV

JAMA Psychiatry 2015.

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