Cognitive Therapy for Depression Sustains Improvement Longer Than Drugs

Laurie Barclay, MD

May 23, 2002

NEW YORK (MedscapeWire) May 24 — Cognitive therapy and antidepressants are equally effective for initial treatment of severe depression, but the enduring effect of cognitive therapy may prove to be more cost-effective in the long run. These controversial findings were presented at a symposium on May 23 at the American Psychiatric Association annual meeting in Philadelphia, Pennsylvania.

"This will be a surprising, controversial finding for many psychiatric professionals," principal investigator Robert J. DeRubeis, MD, from the University of Pennsylvania, said in a news release. "Most believe quite strongly in the efficacy of medication, and psychiatric treatment guidelines call unequivocally for medication in cases of severe depression."

Compared with earlier studies of severely depressed patients requiring hospitalization, this randomized controlled study was significantly larger, involving 240 patients in Philadelphia and Nashville, Tennessee. The study duration of 16 months was also considerably longer. After 4 months of acute treatment, patients who showed improvement in the initial phase underwent an additional year of treatment. Both study phases were placebo controlled.

"We looked at depression somewhat differently than prior studies," said co-author Steven D. Hollon, PhD, from Vanderbilt University in Nashville. "The question that has most often been asked in studies is, 'What gets people better faster?' We asked, 'What will keep depression away over the long term?' "

By the 16-week posttreatment assessment, response rates were identical (57%) for both pharmacotherapy and cognitive therapy. Among those who continued into the second phase of the study, 75% of patients who received cognitive therapy avoided relapse, compared with 60% of patients receiving antidepressants and 19% receiving placebo. The effect of either cognitive therapy or medication was significantly better than placebo, and a brief course of cognitive therapy was better than a similarly brief course of medication in the year-long continuation phase.

"These results suggest that even after termination, a brief course of cognitive therapy may offer enduring protection comparable to that provided by ongoing medication," DeRubeis said.

There were some subgroup differences: patients with comorbid generalized anxiety disorder responded better to medications than they did to cognitive therapy, whereas patients without comorbid generalized anxiety disorder responded better to cognitive therapy than they did to medications. High-risk patients with histories of chronic depression or multiple recurrences were most likely to require either continuation medication or prior cognitive therapy.

Over the 16-month study, antidepressant treatment cost $2590 on average compared with $2250 for cognitive therapy. This gap grew with time because antidepressants must be administered continually to be effective.

"Some proponents of medication for severely depressed patients have suggested that cognitive therapy is impractical on the basis of cost," DeRubeis said. "Our study indicates that isn't true, especially over the long term."

The National Institute of Mental Health and GlaxoSmithKline funded this study.

APA Annual Meeting. Presented May 23, 2002.

Reviewed by Gary D. Vogin, MD


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