Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Second Generation Antidepressants & CBT

A look at initial treatment of acute depression

Publish date:: December 22, 2015

There was no difference in treatment effects of second generation antidepressants and cognitive behavioral therapies (CBTs), either alone or in combination, in major depressive disorder (MDD), and therefore both treatments should be made accessible to primary care patients with MDD. This according to a meta-analysis of 11 randomized controlled trials comparing second generation antidepressants and CBT. Researchers found:

• There was no statistically significant difference in effectiveness between second-generation antidepressants and CBT for response (RR=0.91), remission (RR=0.98), or change in 17 item Hamilton Rating Scale for Depression score.

• No significant differences were found in rates of overall study discontinuation (RR=0.90) or discontinuation attributable to lack of efficacy (RR=0.40).

• More patients treated with a second-generation antidepressant than receiving CBT withdrew from studies because of adverse events (RR=3.29, not statistically significant).

Citation: Amick HR, Gartlehner G, Gaynes BN, et al. Comparative benefits and harms of second generation antidepressants and cognitive behavioral therapies in initial treatment of major depressive disorder: systematic review and meta-analysis. [Published online ahead of print December 8, 2015]. BMJ 2015;351:h6019. doi: 10.1136/bmj.h6019.

Commentary: Approximately 7% of United States adults have an episode of major depression each year. Some of those people seek treatment and many do not. Of those who seek treatment, many have preferences about whether they would like their depression treated using medicines or psychotherapy. CBT has rock solid data showing efficacy in the treatment of major depression and may be more effective than medication in preventing relapse of depression.^1,2 This meta-analysis reliably shows that both CBT and second-generation antidepressants have equal efficacy, and while not reaching statistical significance, there is a suggestion that CBT has fewer adverse effects. The decision about whether to recommend CBT, antidepressant, or both is best based on individualized assessment taking into account patient preferences. —Neil Skolnik, MD

1. Keller MB, McCullough JP, Klein DN, et al. A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. NEJM 2000;342:1462-70. doi: 10.1056/NEJM200005183422001.

2. Hollon SD, DeRubeis RJ, Shelton RC, et al. Prevention of relapse following therapy vs medications in moderate to severe depression. Arch Gen Psychiatry 2005;62(4):417-22. doi:10.1001/archpsyc.62.4.417.

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