Subject:
Depression

Short Description:
Cognitive Behavioral Therapy for Treatment Resistant Depression

Background:
We have an abundance of medications to treat depression, but “treatment resistance” remains all too common. Accordingly, there has been a rise in the number of “augmentation” or “adjunctive” medications to address this population. Unfortunately, comparable attention has not been drawn to the role of psychotherapy in the management of treatment-resistant depression.To evaluate the effect of psychotherapy on treatment-resistant depression, investigators recruited 469 patients with depression who had taken antidepressants (mostly SSRIs) for at least six weeks without a response—their definition of “treatment resistance.” They randomized patients to usual care (which included medications and any other treatment options selected by their general practitioner) or usual care plus cognitive behavioral therapy (CBT). CBT was delivered by part-time therapists, nine of whom conducted the vast majority of therapy. Patients completed a mean of 6.3 months of treatment, with a median of 11 sessions of CBT over the first six months.At the end of six months, nearly half (46%) of the patients randomized to CBT met criteria for treatment response (defined as a decrease of >50% in scores on the Beck Depression Inventory, BDI), compared with only 22% of the usual care group, with a threefold increased odds of response (odds ratio of 3.26). Patients undergoing CBT were also more likely to experience remission (BDI score <10) (28% vs 15%) and have fewer symptoms of anxiety or panic at the end of six months. On average, BDI scores were 5.7 points lower in the intervention group, with an effect size of 0.53. The number needed to treat (NNT) for response was 4, while the NNT for remission was 8.Those who had experienced CBT within the last three years were excluded, as were those with bipolar disorder, psychosis, or a substance use disorder. Adherence to medications was high in both groups, although fewer than half of the patients experienced a change in dose over the course of their treatment (Wiles N et al, Lancet 2013;381(9864):375–384).

TCPR’s Verdict: Treatment resistance in depression is widespread, and common solutions include switching to a different antidepressant or adding another medication to augment the first. This study is the first large-scale, randomized trial of CBT as an “augmenting agent,” and shows that CBT is highly effective in reducing symptoms of depression and even in helping to achieve remission.