This news release from RTI International states that cognitive behavioral therapy (CBT) and second generation antidepressants are equally effective as first-line treatments for treating major depressive disorder (MDD). CBT is a general term for a wide variety of psychotherapy strategies that involve talking about one’s thoughts, feelings and behaviors in order to make positive changes. Second generation antidepressants refer to drugs introduced in the 1980s and 1990s and include the brand name drugs Prozac, Lexapro and Wellbutrin. The findings reported come from a mega-analysis of 11 previous randomized controlled studies that looked at CBT and antidepressant outcomes. The claim that they are equally effective as first-line treatments for MDD conflict with current practice guidelines recommended by the American Psychiatric Association and the British Association for Psychopharmacology that state, “psychotherapy is sufficient for treating mild depression, antidepressant medications (ADMs) should be used to treat severe depression in the context of major depressive disorder.” The news release’s claims about benefits aren’t backed up by hard numbers showing what the study authors found.
An estimated 15.7 million (or 6.7% of adults) U.S. adults experience major depression at least once during 2013, according to the National Institute of Mental Health. Antidepressants as a class have been one of the top 5 prescribed drugs in the U.S. for the last dozen years. The cost and adverse reactions caused by antidepressant medications is significant and an alternative such as CBT is important to know about.
The release gives a slight nod to costs without saying very much. It states, “However, psychotherapy can be time-consuming and may be substantially more expensive, depending on the patient’s insurance benefits.” Medications and CBT both have costs so it would have been nice to compare them.
There was no quantification of benefits. That’s a big omission considering people with major depressive disorder are being told that talk therapy and medications yield the same outcome.
Some of the important quantifiers missing include:
How long was the treatment? What percent improved after treatment? How much did they improve? What was the rate of relapse? How long did they improve?
The release mentions harms from both CBT and antidepressants. While promoting the advantages of CBT over medications, the release discusses some harms from antidepressants (“constipation, diarrhea and dizziness”) but didn’t touch on the more serious harms associated with SSRIs, particularly when going through withdrawal.
This was a systematic review that looked only at randomized, controlled trials, which should reflect high quality, reliable results. While we’ll award a Satisfactory rating, we wish that the release had done more to explain where this type of study sits in the evidence hierarchy and how it differs from other types of research. Some comment on limitations of the included studies would also have been appropriate — for example the study itself said this: “Results should be interpreted cautiously given the low strength of evidence for most outcomes.”
The release doesn’t use fear mongering language. Perhaps it even under-stressed the ill effects of major depression.
The release notes that the Agency for Healthcare Research and Quality (AHRQ) funded the study. AHRQ is a government agency that studies and promotes improved quality in health care.
While the release is about comparative trials it didn’t delve into what improvement means.
While CBT is in wide use, the release glides over the long wait times even people with health insurance must wait to be matched with a CBT therapist. In some states, the wait can take months. In addition, the release notes that most patients see their primary care physician first. We are unclear on what percentage of primary care physicians are trained in CBT and are willing to offer it.
This meta-analysis research on CBT and antidepressants has been around the block a few times. A similar study involving 16 studies and 1700 patients and with a similar conclusion was published in JAMA Psychiatry in September 2015. Prior to being published in the BMJ, this research was presented at a 2014 neurology conference.
The release doesn’t use unjustifiable language. Some of the language is muddied in that it doesn’t spell out the difference between major depressive disorder and other types of depression.