Therapy, Antidepressants Similarly Effective for Depression

Marcia Frellick

February 09, 2016

Cognitive behavioral therapy (CBT) is as effective for treating depression as antidepressants, and given its relative lack of potential harms, should be strongly considered as the first-line treatment, according to a new guideline issued by the American College of Physicians (ACP).

The guideline is based on a systematic review of randomized controlled trials from 1990 through September 2015 comparing the benefits of second-generation antidepressants (SGAs) and nonpharmacologic interventions such as psychotherapies, complementary and alternative medicines (including acupuncture and St John's wort [Hypericum perforatum]), and exercise. The guideline was published online February 9 in the Annals of Internal Medicine.

Physicians may be surprised to learn CBT is as effective as antidepressants, Amir Qaseem, MD, PhD, MHA, the ACP's vice president of clinical policy and lead author of the guideline, told Medscape Medical News.

They are often more likely to recommend antidepressants first because prescribing medication does not require finding a provider and lining up services and meetings, as CBT does, and because the scope of what is involved with therapy may be unclear to primary care physicians, he said. But the trade-off may be the potential for more adverse effects.

"[SGAs] tend to have more harms," he explained, including headaches, insomnia, constipation, diarrhea, sexual dysfunction, dizziness, and drowsiness. The guidelines also note that harms associated with SGAs are probably underrepresented in the trials studied.

Problems With St John's Wort

Another important message in the guideline is regarding the potential problems with the popular herbal therapy St John's wort, sold over the counter at drug stores and in health food stores.

Patients increasingly are asking about the herb as a natural treatment for depression, said Dr Qaseem.

Although the guideline shows low-quality evidence that St John's wort may be as effective as SGAs for treating major depressive disorder, and moderate-quality evidence showed that St John's wort was better tolerated than SGAs, the committee cannot recommend it as a treatment, he said.

The first problem is that because it is not regulated by the US Food and Drug Administration, amounts of the active ingredient differ by the bottle, making comparison with amounts tested in clinical trials difficult, he explained.

"We don't know the standards of purity and potency in the US at all," he said.

The second problem is that St John's wort also is known to interfere with the efficacy of other treatments, including oral birth control, and drugs for HIV and transplant rejection. Adverse effects associated with it may include gastrointestinal symptoms, skin reactions, fatigue, dizziness, headache, and dry mouth, and it is contraindicated in patients taking monoamine oxidase inhibitors or selective serotonin re-uptake inhibitors.

Dr Qaseem said it is important for physicians and patients to discuss the options and decide on a first-line therapy together.

Guidelines in Line With American Psychiatric Association Advice

The guidelines are in line with American Psychiatric Association guidelines on major depressive disorder from 2010, which also showed that CBT and SGAs are similarly effective, said Laura Fochtmann, MD, MBI, professor of psychiatry, pharmacological sciences, and biomedical informatics at Stony Brook University School of Medicine in New York.

She told Medscape Medical News there are several factors that should be considered when physicians talk with their patients about which to choose: whether there is a trained CBT provider in the patient's vicinity, whether the patient is covered by insurance for the service and whether the available provider accepts the insurance, whether the patient can get appointments in evening hours, and what the patient prefers.

"There are all sorts of barriers to psychotherapies that aren't present with medications," she said. "It is sometimes seen as an easier option to take medication." She noted that this may have led to the prevalence of medication over therapy, "even though we've known for quite a while that they were equally efficacious."

Costs between the two are hard to estimate even for physicians, she said, as insurance coverage varies significantly.

The new ACP guideline draws nonpsychiatric clinicians' attention to the importance of recognizing and identifying depression when patients present with depressive symptoms in primary care, said Dr Fochtmann.

Physicians can help educate patients that this is a treatable condition and that there are effective treatment options.

"I think in that way, it's an important recommendation," she said.

ACP's recommendations are based on a systematic evidence review by the Agency for Healthcare Research and Quality.

Financial support for this guideline comes exclusively from the ACP operating budget. Three coauthors were recused from voting on this guideline and from chairing during the discussion of the guideline for indirect financial or direct intellectual conflicts. Dr Fochtmann has a contract with the American Psychiatric Association to write practice guidelines.

Ann Intern Med. Published online February 9, 2016. Full text

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