Trial compares long-term effects of psychotherapy and antidepressants on depression symptoms

In the current issue of Psychotherapy and Psychosomatics there are data about the long term-effects of a form of psychotherapy in depression compared to medication. Compared to episodic depression, only a limited number of follow-up studies for chronic depression exist despite its poor long-term course. For episodic depression, psychotherapy has repeatedly been shown to result in more sustainable treatment effects than antidepressant medication. However, relapse rates remain high even after response to acute phase psychotherapy at approximately 30% after 1 year and approximately 50% after 2 and more years. For patients suffering from chronic depression, the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) has shown promising results during acute treatment, yet data on the sustainability of these effects is scarce.

The primary objective of this naturalistic follow-up (German Clinical Trials Register: DRKS00008935) to the randomized clinical trial by Schramm et al. was a direct comparison of the long-term sustainability of CBASP versus escitalopram plus clinical management (ESC).

Forty-three patients (73%) of the original ITT sample (n = 43/59) participated; 12 patients (20%) could not be reached, and 4 patients (7%) declined participation. Follow ups took place a mean of 4.5 years after trial completion. Only 7% of participants had not received further antidepressant treatment during the follow-up period; 45% had received both antidepressant medication and psychotherapy. Of those participants who had received escitalopram during the clinical trial (n = 31), approximately one-third (31%) were still taking escitalopram at follow-up, 41% had switched to a different antidepressant medication, and 28% had stopped taking any antidepressant medication.

Contrary to the Authors' primary hypothesis, CBASP did not result in more sustainable long-term effects on depression symptoms and quality of life compared to ESC. Rather, there appeared to be a trend favoring ESC. With an initial sample size of n = 59 and further attrition to follow-up, the study was underpowered and these results have to be interpreted with caution. One possible explanation for our results is that 28 weeks of acute psychotherapy may be insufficient for patients suffering from chronic depression who may benefit from longer treatment duration and may require maintenance care. Roughly one-third of patients acutely treated with escitalopram had continued taking escitalopram throughout the follow-up period. In contrast, there is still an unsatisfyingly low level of dissemination of specific psychotherapy for outpatient treatment. Previous research has shown a progressively increasing occurrence of tolerance phenomena to antidepressant medication, a risk of severe side effects, and considerable withdrawal symptoms following the discontinuation of antidepressant medication. Internet delivery could help to increase the dissemination and cost-effectiveness of specific maintenance psychotherapy to provide a viable alternative to long-term antidepressant medication.