Depression: Treatment Beyond Medication

Major depressive disorder affects nearly 7 percent of people in the US aged 18 and up, according to the Depression and Bipolar Support Alliance. Those who seek treatment will most likely be prescribed a second-generation antidepressant medication such as a selective serotonin reuptake inhibitor (SSRI), tricyclic antidepressant (TCA), or a monoamine oxidase inhibitor (MAOI). Some recent studies, though, suggest that these types of medications are not quite as effective as previously believed. A 2010 JAMA Psychiatry study found no difference in antidepressant medication versus placebo in those with mild to moderate depression. The large-scale Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study found that only about one-third of study participants reached remission after being prescribed a single antidepressant medication—most had to try several different drugs before seeing their symptoms diminish. There are alternative treatments to antidepressant medication, and in February 2016, the American College of Physicians issued a new clinical practice guideline suggesting that one—cognitive behavioral therapy (CBT)—is an equally viable choice to treat adults with depression. That new guideline was published in the Annals of Internal Medicine.

Not just talk therapy

CBT is a type of directed and driven talk therapy where a patient works one-on-one with a trained counselor, says Claudi Bockting, a professor of clinical psychology at the University of Utrecht in the Netherlands.

“It’s based on the idea that our cognition has a large impact on what we actually feel. So what CBT does is try to teach people to be aware of what they think and feel, and then check whether those ideas are correct,” she says. “This is important because we know in a lot of conditions like depression, patients are negatively biased. They have thoughts that are more negative or more catastrophic than the reality actually is. So CBT helps them learn to be aware of these negative thoughts and to help them adjust them so they can feel better. There’s a lot of evidence that CBT is quite effective for the treatment of a lot of mental disorders—and that includes depression.”

Bockting says that there are many advantages to CBT for people with depression. For one, a psychiatrist or even a medical doctor is not required to give the treatment. Psychologists can be trained to administer this type of therapy and can even do so using telephone- or web-based mental health programs, a boon to those seeking treatment in areas where in-person care may be scarce. Second, studies suggest that CBT is superior to antidepressant medication when it comes to preventing relapse in people with depression.

“We know that, for about 80 percent of patients, depression is a recurring disorder. But CBT seems to give patients with depression some tools to help protect them against future relapses,” she says. “That’s why in the Dutch guidelines for treatment we recommend CBT as a first choice of treatment in cases of mild depression.”

Thinking beyond drugs

When asked why the American College of Physicians (ACP) decided to release this practice guideline now, Michael Barry, an internal medicine physician at Massachusetts General Hospital and a member of the organization’s clinical guidelines committee, says that the evidence has finally converged to the point it supports CBT’s effectiveness.

“We’ve been interested in whether there are effective alternatives to second generation antidepressants. So we’ve been looking at behavioral therapies like CBT but also things like exercise and alternative medicines,” he says. “But the evidence on CBT is the most striking. The accumulation of evidence over time shows that CBT has similar effectiveness to these medications and the patient withdrawal rates from CBT were no higher—in fact, they are probably lower—than with second generation antidepressant medication. So now physicians have two different and effective options to choose from when determining treatment for a patient with depression.”

But does that mean that doctors should be shying away from antidepressant medication altogether?  Madhukar Trivedi, a psychiatrist at the University of Texas Southwestern Medical Center, and one of the principal investigators on the STAR*D antidepressant study, says that he does not think so.

“The medication vs. CBT debate is like the whole mind/body debate. Everyone has different perspectives and we could talk about it forever,” he says. “The evidence tells us that medications are effective, but the efficacy is modest. Similarly, the evidence tells us that psychotherapies like CBT are effective, but the efficacy is modest. But both work pretty well in those with less severe depression. So, in my opinion, all of these treatment options should be available and be considered in the clinical judgment for each patient by the physician.”

The right therapy, the first time

Barry thinks the new ACP guideline helps offer clinicians more choices for treatment, and that’s a good thing. “What we see is that there are two effective therapies available for people with depression and that gives both doctors and patients working with their clinicians a choice on how to approach and treat the condition,” he says. “Some patients might prefer medication. Some might prefer not to take a pill and would like an alternative therapy. Being able to offer people more than one good alternative to manage a medical problem is always a good thing, from my perspective.”

Given the converging evidence on its effectiveness and its protective effects against future relapses, Bockting thinks, more doctors should opt for CBT before prescribing a drug when treating those with mild or moderate forms of depression.

“Most people who are treated for depression will get antidepressant medication. This is not just the case in the United States—this is also the case in Europe,” she says. “But we want to be able to help people not just with one episode of depression but also help them against future recurrences. And there are a lot of studies that now show that even just eight sessions of CBT can protect these patients against relapse over years and years.”

There are treatments beyond antidepressants and CBT, too, Trivedi says. Transcranial magnetic stimulation (TMS), physical exercise, and ketamine have all shown some positive effects on low mood in studies. To him, the more important question is how doctors can know which treatment will be the most effective for each individual patient. To that end, he is running a clinical trial called the Establishing Moderators and Biosignatures of Antidepressant Response for Clinical Care for Depression (EMBARC).

“We’re learning that what we call depression today may actually be 10, 12, maybe even 15 different diseases,” he says. “So where we hope to go is to find biomarkers so we can identify for groups of patients, or individual patients, for whom one treatment or another treatment is better. Some patients may actually need more than one treatment to get better. It’s possible. But we don’t know yet. We still have a lot of work to do. But until we do that work, it’s good that we have some different options we can try.”