Health & Wellness

New depression guidelines offer a drug-free treatment for some patients

While drug treatment for depression has been a life saver for many people, new research shows psychotherapy, specifically cognitive behavioral therapy, is just as effective.

The findings, published Monday in the Annals of Internal Medicine, will comprise the latest evidence-based clinical guideline recommendations for depression treatment from the American College of Physicians (ACP.) The group is the largest medical specialty organization in the U.S. and includes among its membership internal medicine physicians, the very doctors who are often the first-line providers for many of the 16 million Americans already diagnosed with depression.

In their analysis of studies ranging from 1990 through September 2015, the researchers graded the evidence on the safety and effectiveness of various treatments for depression, including psychotherapeutic approaches, alternative and complementary approaches like St. John’s wort, and drug approaches, specifically focusing on the second-generation antidepressants.

These medications include, among others, the commonly prescribed selective serotonin reuptake inhibitors, or SSRIs, such as fluoxetine (Prozac), as well as serotonin and norepinephrine reuptake inhibitors, or SNRIs, such as duloxetine or Cymbalta.

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What they found was “moderate-quality evidence” showing that cognitive behavioral therapy (CBT) and second-generation antidepressants are similarly effective for depression treatment in terms of response and quality of life, among others factors. Discontinuation rates for both approaches were also about equal.

Since CBT and medications are both good choices for initial treatment of depression, the guidelines emphasize that treatment should be chosen after a doctor discusses not only the advantages and disadvantages of each option, but also patient preference, which includes their beliefs, costs and treatment availability.

Related: What to say (or not say) to someone who is depressed

While some patients may prefer drug therapy for depression treatment, many others do not want to deal with the potential side effects, such as weight gain or sexual difficulties, explains study co-author and internal medicine specialist Dr. Michael Barry of Massachusetts General Hospital.

“What’s new here, and what was new for me, is that we now have documentation that cognitive behavioral therapy, which is very goal directed and time limited, can improve depression,” says Barry, who is also a member of the ACP’s Clinical Guidelines Committee. “It is gratifying to know that patients have more than one option and that we can feel confident in those choices.”

Cognitive behavioral therapy is a problem-oriented therapeutic strategy that helps patients identify and find ways to effectively deal with current problems and negative thoughts and behaviors. But finding qualified therapists can be tough.

“The reality is that we don’t have enough qualified providers to cover all of the therapy needs out there,” says psychiatrist Dr. Niranjan Karnik of Rush University Medical Center.

That access issue may lead to other approaches to therapy such as online education and treatment, alone or in combination with office treatment and medication, he adds.

Nonetheless, the new guidelines are a welcome addition.

“Primary care doctors are the backbone of depression treatment and these (guidelines) are music to my ears,” says psychiatrist Dr. Ken Duckworth, medical director of the National Alliance for Mental Illness (NAMI). “The fact that patient choice is being emphasized is very important.”

But patients need to know that “. . . cognitive behavioral therapy is not a picnic,” he says. “People may be surprised by the hard work that takes.”

When it comes to alternative approaches, the researchers found “low-quality evidence” that St John’s wort, a popular treatment for depression in Europe, may be as effective as the second-generation antidepressants. But there was “moderate quality evidence” showing it was better tolerated.

“If a patient really wanted to try St. John’s wort I would first want to get an assessment as to the severity of depression,” says Barry, who is also medical director of the Stoeckle Center for Primary Care Innovation. “If they were mildly depressed, and they were insistent, I might consider it. But based on the evidence we have, that would be tough.”

That’s because poorly controlled depression can lead to a host of medical problems and suicide, he says.

There is also the issue of safety since St. John’s wort is not regulated by the Food and Drug Administration and patients may not be able to get the same quality product as those patients who were involved in studies. It is also not without side effects such as dry mouth and dizziness, and can cause serious drug-to-drug interactions.

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