April 4, 2005 — New research challenges the widely accepted idea that drugs are the only effective, initial treatment for major depression.

“The message is that there are clearly at least two options for patients who are suffering from moderate to severe forms of depression,” says the University of Pennsylvania’s Robert J. DeRubeis, PhD, who led one of the research teams.

The researchers say that their findings do not support current guidelines from the American Psychiatric Association. The guidelines state that most moderately to severely depressed patients require treatment with antidepressant drugs.

“It appears that cognitive behavioral therapy can be as effective as medications,” they write.

Cognitive therapy is a type of talk therapy that involves changing a person’s negative thought patterns.

Fewer CT Patients Relapsed

In the initial study by DeRubeis and colleagues, 240 moderately to severely depressed patients were divided into three treatment groups. A total of 120 were treated with the antidepressant Paxil along with either lithium or the trycyclic antidepressant desipramine, if needed. Sixty patients each were treated with either a placebo pill or cognitive therapy.

Researchers compared antidepressant medication to cognitive therapy and found that response rates were similar for both treatment groups.response rates were similar for both treatment groups.

After 16 weeks of treatment, response rates were the same for patients treated with antidepressants and cognitive therapy. A total of 58% of both groups responded to treatment. In the group of drug-treated patients, 46% experienced few if any symptoms of depression, compared with 40% of the cognitive therapy patients.

A follow-up study showed that relapse after withdrawal from treatment may be a bigger problem for patients treated with drugs than for those who receive cognitive therapy.

This study included 104 of the patients who responded to treatment.

Both studies were published in the April Archives of General Psychiatry.

Patients who responded to cognitive therapy were withdrawn from treatment and compared during the next year with patients who had responded to antidepressants and were either kept on the drugs or were unknowingly switched to a placebo. Relapse was defined as a return, for at least two weeks, of symptoms of major depression.

Researchers found that patients withdrawn from cognitive therapy were less likely to relapse during the continuation phase than patients withdrawn from medication (31% vs. 76%, respectively).

Patients who had received cognitive behavioral therapy were also no more likely to relapse than the patients who kept taking antidepressants.

“The cognitive therapy patients did as least as well as those that stayed on the antidepressants,” DeRubeis tells WebMD.

Access to Care a Problem

American Psychiatric Association spokeswoman Laura Fochtmann, MD, tells WebMD that the study was “strong” and “rigorously designed” and will be considered when the APA revises its treatment guidelines in the future. The guidelines were last updated five years ago.

But Fochtmann questioned whether the depressed patients in the study were truly representative of people with major depression in the community at large. She points out that people with psychosis were excluded from the study, even though many patients with major depression are also psychotic.

The Stony Brook University professor of psychiatry also questioned whether people who seek cognitive therapy in the general community can get the same level of care as the study participants.

“It makes sense that outcomes may be better when the [doctor] has more experience with the treatment, whether it is bypass surgery or cognitive therapy,” she says. “In ordinary clinical settings it may be difficult to find adequately trained therapists. Access to care is a huge, huge issue with cognitive therapy and with many other treatments in mental health.”