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ACP: CBT, second-generation antidepressants 'similarly effective' for major depressive disorder

The American College of Physicians has released evidence-based clinical practice guidelines regarding the treatment of adults with major depressive disorder.

Their recommendations state that physicians should treat adults who have major depressive disorder (MDD) with cognitive behavior therapy (CBT) or second-generation antidepressants (SGAs).

The guidelines, authored by Amir Qaseem, MD, PhD, and colleagues from the Clinical Guidelines Committee of the ACP and published in the Annals of Internal Medicine, were issued with a grade noting "strong recommendation, moderate-quality evidence."

"Patients are frequently treated for depression by primary care physicians, who often initially prescribe SGAs," Wayne J. Riley, MD, MPH, MBA, MACP, ACP president, said in a press release. "However, CBT is a reasonable approach for initial treatment and should be strongly considered as an alternative treatment to SGAs where available, and after discussing treatment effects, adverse effect profiles, costs, accessibility, and preferences with patients."

The guideline authors reviewed evidence from MEDLINE, EMBASE, the Cochrane Library, AMED, PsycINFO and CINAHL to evaluate the response, remission, functional capacity, quality of life, reduction of suicidality or hospitalization and harms of nonpharmacologic treatments compared to SGAs, which included serotonin-norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, mirtazapine, bupropion, nefazodone and trazodone.

They reported that low-quality evidence demonstrated no differences in adverse effects or effectiveness between using a first-line treatment of SGAs compared with nonpharmacologic treatments. Moderate-quality evidence demonstrated no differences in treatment discontinuation or response between SGAs and CBT.

"A previous systematic review and the 2008 ACP guideline have shown similar safety and efficacy among the different SGAs," the authors wrote. "Most patients do not achieve remission after the initial treatment with SGAs, in which case switching therapies or augmenting with additional interventions may be warranted."

The guidelines stated that second-line treatment strategies following treatment failure with SGAs, including switching to or augmenting with another drug or nonpharmacologic therapy, were similarly effective based on low-quality evidence.

Additionally, the authors noted that, despite data limitations on population subgroups, they found evidence that St. John's wort showed similar efficacy and rates of adverse events compared with SGAs in older patients.

"Moderate-quality evidence suggests that discontinuation rates are similar for CBT and SGAs, although discontinuation due to adverse events is non-statistically significantly increased with SGAs," the authors wrote. "However, harms associated with SGAs are probably underrepresented in the included trials. Thus, we conclude that CBT has no more — and probably fewer — adverse effects than SGAs."

Qaseem and colleagues also cited reported lower relapse rates with CBT as well as side effects from SGAs that can range from mild to major.

"Although SGAs are often initially prescribed for patients with depression, CBT is a reasonable approach for initial treatment and should be strongly considered as an alternative treatment to SGAs where available," they concluded. – by Chelsea Frajerman Pardes

Disclosures: The researchers report no relevant financial disclosures.