Cognitive behavioral therapy (CBT) and second-generation antidepressants have similar efficacy and are both viable choices for adult patients who have major depressive disorder, according to a new clinical practice guideline published online Feb. 8 in the Annals of Internal Medicine.
“Although second-generation antidepressants are often initially prescribed for patients with depression, CBT is a reasonable approach for initial treatment and should be strongly considered as an alternative,” said Amir Qaseem, M.D., Ph.D., of the American College of Physicians, Philadelphia, and his associates on the clinical guidelines committee (Ann Intern Med. 2016 Feb 9; doi: 10.7326/M15-2570).
Until now, the relative benefits and harms of antidepressant medications vs. other therapies were unclear. The guideline was intended “to summarize and grade the evidence on the comparative effectiveness and safety of nonpharmacologic treatments and [antidepressants], alone or in combination.”
It is based on a systematic review and meta-analysis of 45 English-, German-, and Italian-language randomized, controlled trials of at least 6 weeks’ duration published from 1990 to September 2015, as well as relevant unpublished research. The Evidence-Based Practice Center of the federal Agency for Healthcare Research and Quality and the University of North Carolina at Chapel Hill conducted the review.
The nonpharmacologic treatments that were assessed included:
• Cognitive therapy, which aims to correct negative thoughts and false self-beliefs.
• CBT, which includes a behavioral component such as activity scheduling and homework.
• Acceptance and commitment therapy, which uses mindfulness techniques to help patients accept problems and counter negative thoughts;
• Interpersonal therapy, which focuses on relationships.
• Psychodynamic therapy, which targets past experiences and conscious and unconscious feelings.
• Third-wave CBT, which focuses on thought processes to help patients achieve awareness and acceptance.
The complementary and alternative treatments that were examined included acupuncture, meditation, yoga, and the use of omega-3 fatty acid supplements, SAMe, or St. John’s wort. Exercise as practiced individually, in informal groups, or in classes also was assessed.
The second-generation antidepressants that were assessed included selective serotonin reuptake inhibitors (such as fluoxetine, sertraline, and paroxetine), serotonin norepinephrine reuptake inhibitors (such as venlafaxine and duloxetine), selective serotonin norepinephrine reuptake inhibitors, and bupropion, mirtazapine, nefazodone, and trazodone.
The outcomes of interest with antidepressants were response rates, remission rates, speed of response, speed of remission, relapse rates, adverse events, quality of life, functional capacity, reduction of suicidality, and reduction of hospitalization.
Moderate-quality evidence showed no significant difference between antidepressants and CBT in either treatment response or discontinuation of treatment because of adverse effects.
Therefore, the guideline strongly recommends that “clinicians select between either CBT or second-generation antidepressants to treat patients with major depressive disorder after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient,” Dr. Qaseem and his associates said.
The guideline also states that most patients do not achieve remission after initial treatment with antidepressants, so “switching therapies or augmenting with additional interventions may be warranted.”
Regarding other treatments and other outcomes, the evidence was considered too sparse and of such low quality that it would not support any other recommendations at this time. Most of the reviewed studies were flawed by high dropout rates, dosing inequalities, small sample sizes, and poor evaluation of adverse events, according to Dr. Gerald Gartlehner and his associates at the Evidence-Based Practice Center, Chapel Hill, N.C. (Ann Intern Med. 2016 Feb 9; doi: 10.7326/M15-1813).
The guideline and the review/meta-analysis of the literature are available at www.annals.org. The guideline work was supported exclusively by the American College of Physicians. Dr. Qaseem disclosed no conflicts of interest. Complete disclosures for the members of the clinical guideline committee are available at www.acponline.org.