Patients with depression who have not responded to pharmacologic treatment should be offered cognitive behavioral therapy (CBT), suggest the results of a randomized trial conducted in a primary care setting.
Among 469 patients who had not responded to treatment with an antidepressant for at least 6 weeks, those assigned to CBT on top of usual care (n=234) had double the response rate of patients assigned to usual care only (n=235) at 6 months.
Participants in the intervention group received 12 sessions of individual CBT, with up to six additional sessions if deemed clinically appropriate by the therapist; the intervention period lasted a mean of 6.3 months. Participants assigned to usual care could be referred for counseling, CBT, or to secondary care if clinically appropriate.
Response was defined by a 50% reduction in depressive symptoms as measured on the Beck Depression Inventory (BDI) - 95 (46%) patients in the intervention group achieved this by 6 months, compared with 46 (22%) in the usual-care group, translating into a threefold increased odds for a response.
The benefit of CBT was also seen for the more stringent outcome of remission, note authors Nicola Wiles (University of Bristol, UK) and colleagues. At 6 months, 57 (28%) of the intervention group achieved this, defined as a BDI score of less than 10, compared with 32 (15%) of the usual-care group, giving an odds ratio of 2.3.
Furthermore, these improvements were maintained over 12 months.
The authors note that adjustment for baseline imbalances including BDI score, previously described antidepressants, whether the general practice had a counselor, and the duration of the present episode of depression did not impact on the findings.
The majority (70%) of patients in the study had been on antidepressant medication for a year or more, which Wiles and team say would have minimized any effect of occasional non-adherence.
"A substantial proportion of people do not respond to antidepressants and our results have provided robust evidence that CBT given as an adjunct to usual care that includes antidepressant medication is an effective treatment in reducing depressive symptoms and improving quality of life in this population," the authors conclude in The Lancet.
Michael Otto (Boston University, Masachusetts, USA) and Stephen Wisniewski (University of Pittsburgh, Pennsylvania, USA) comment in a related editorial that the "promising" findings add to the "already impressive" evidence for the efficacy of CBT as a first-line alternative to pharmacologic treatment, and as a strategy for antidepressant discontinuation, with retention of benefit over time.
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