Evidence synthesis for determining the efficacy of psychotherapy for treatment resistant depression
BACKGROUND: Major depressive disorder (MDD) is a prevalent disorder impacting an estimated 13% of the general population, and a third of the veteran population. Of the patients who experience at least one depressive episode, approximately 20% will experience chronic depression and 60-85% will experi...
|Corporate Authors:||, , ,|
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Department of Veterans Affairs, Health Services Research & Development Service
|Series:||Evidence-based synthesis program
|Collection:||National Center for Biotechnology Information - Collection details see MPG.ReNa|
|Summary:||BACKGROUND: Major depressive disorder (MDD) is a prevalent disorder impacting an estimated 13% of the general population, and a third of the veteran population. Of the patients who experience at least one depressive episode, approximately 20% will experience chronic depression and 60-85% will experience recurrence and relapse. Antidepressant medications are the most commonly prescribed treatment modality for MDD and are often the first line of treatment in primary care settings. However, fewer than 50% of patients fully remit after adequate dosage of antidepressant treatment. Treatment options for these "treatment resistant" patients vary but typically involve using other psychoactive medications as augmentation (i.e., addition of another medication) or substitution treatment (i.e., switching medications).|
Less attention has been paid to using psychotherapy as an augmentation or substitution treatment for treatment resistant patients, despite psychotherapy being associated with clinical improvements in MDD comparable to those achieved with antidepressants. The current review will address the effectiveness of psychotherapeutic approaches as a second step treatment for MDD in patients who do not achieve remission after initial treatment with antidepressants.
Question: In primary care patients with major depressive disorder who do not achieve remission with acute phase antidepressant treatment, is empirically based psychotherapy used as an augmentation or substitution treatment more effective than control for achieving remission? SUMMARY: In summary, two good quality, moderate-sized trials showed equal benefit from augmenting antidepressant medication with CT and from active medication management, one fair quality small study showed lithium augmentation to be more beneficial than CT, and one fair quality trial showed short-term benefit from augmentation through 16 sessions of DBT. A moderate-sized, good quality study and a small, poor quality study found equal benefit from substituting CT for antidepressant treatment and from continuing management of depression with medication. There was significant heterogeneity in study designs, sample sizes, and comparator groups, and most studies were underpowered to detect moderate effect sizes.
We conclude that current trials do not support favoring psychotherapy over antidepressant medication for mid-life adults with treatment resistant MDD; however, psychotherapy appears to be an equally effective treatment compared to antidepressant medication and is therefore a reasonable treatment option for this demographic. Whether these results are directly applicable to Veterans is uncertain because most study samples were mid-life adults, more than 50% female, and medical and psychiatric co-morbidity was incompletely described. The limited number of studies, mixed effects and uncertain applicability to Veterans suggest a need for additional trials to adequately evaluate the potential treatment benefit of psychotherapy for treatment resistant depression
|Item Description:||Title from PDF cover. - "October 2009.". - "Prepared for: Department of Veterans Affairs Veterans, Health Administration Health Services Research & Development Service, Washington, DC 20420. Prepared by: Durham Veterans Affairs Medical Center/Duke Evidence-based Practice Center, Durham, NC.". - Mode of access: World Wide Web|