Clinical Question

In adults with depression, is treatment with antidepressants more effective than counseling?

Evidence-Based Answer

Both antidepressant medications and psychologic treatment are beneficial for adult patients with mild to moderate depression, with no consistent evidence that one type of treatment is more effective than the other. [Strength of recommendation: A, based on randomized controlled trials (RCTs) and systematic reviews]

There is limited evidence that antidepressant medications and cognitive behavioral therapy are similarly effective for patients with severe depression [Strength of recommendation: B, based on a single RCT]

Evidence Summary

By 2020, depression is expected to be the second most common cause of disability worldwide.¹ Current numbers show that major depression will affect 4.9 to 17.9 percent of U.S. residents sometime during their lifetimes; 20 to 30 percent of this group will experience a chronic, relapsing course.² Ninety percent of depression is treated by primary care physicians.³

For adults with mild to moderate depression, there is no direct evidence that drug or nondrug therapy is superior. Prescription antidepressants are effective at all levels of severity, but systematic reviews have shown no differences in outcomes between any classes of antidepressants.⁴ Different types of psychotherapy (including cognitive therapy and interpersonal psychotherapy) are also effective for managing mild to moderate depression.¹ However, consistent evidence is lacking to make a statement about the relative effectiveness of different types of psychotherapies compared with each other or with drug treatment. One RCT⁵ comparing nefazodone (Serzone, removed from the U.S. market in May 2004 because of hepatotoxicity) with cognitive behavioral therapy over a 12-week period demonstrated similar effectiveness for each treatment alone. Another RCT⁶ of 240 outpatients with moderate to severe depression compared the effectiveness of paroxetine (Paxil) and other medications with cognitive behavioral therapy. Both treatment types were found to be effective, but the degree of effectiveness for cognitive behavioral therapy was dependent on therapist experience, and the overall number of patients in the therapy group was small (n = 60).⁶

An evidence report⁴ from the Agency for Healthcare Research and Quality states that data are too limited to determine if newer antidepressants are more or less effective than psychosocial therapies. Options for pharmacologic and psychotherapeutic treatment of resistant depression (i.e., depression that has not remitted after a firstline drug therapy) are the subject of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial,² with results expected in 2006.

Recommendations from Others

The Institute for Clinical Systems Improvement states in an evidence-based guideline that mild to moderate depression can be treated with psychotherapy instead of, or in addition to, pharmacotherapy.⁷ The guideline also states that cognitive behavioral therapy, interpersonal therapy, and antidepressant medications are equally effective in treating mild to moderate levels of major depression.⁷ The Veterans Health Administration clinical practice guideline states that psychotherapy generally is an appropriate treatment for all forms of depression managed in the primary care setting, and that because there are no demonstrated differences in treatment outcomes between pharmacotherapy and psychotherapy, patient choice should be strongly considered in treatment planning.⁸

Clinical Commentary

The appropriate treatment of depression is of special interest to primary care physicians, who treat the majority of this illness. Although it is reassuring that both antidepressant medication and psychological treatments are effective for patients with mild to moderate disease, physicians are left with the practical consideration of choosing which therapy to use, knowing that neither has yet been shown to be superior. Individualizing the treatment decision requires consideration of local psychotherapy resources, relative expense of treatments, insurance coverage, and response to past therapies. Both patient and physician preferences are appropriate factors to consider when planning treatment for depression.