CBT, Antidepressants Are Equally Effective in Treatment-Naïve Patients

Current guidelines for treating major depressive disorder (MDD) recommend that clinicians consider both the clinical features of the disorder and patient preference when choosing the initial form of treatment. A study published in AJP in Advance in March suggests that while antidepressants and psychotherapy appear to be equally effective in treatment-naïve MDD patients, those matched with their preferred treatment may be more likely to complete therapy.

“These results suggest that patients who receive their preferred treatment may invest more fully in their treatment, which makes the finding that preference does not affect improvement all the more striking,” Boadie Dunlop, M.D., director of the Mood and Anxiety Disorders Program at Emory University School of Medicine, and colleagues wrote. “This discrepancy implies that biological or psychosocial factors are stronger determinants of treatment efficacy than patient preference.”

The study was a part of the Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) trial that aimed to identify biological and psychological factors predictive of treatment outcomes in major depressive disorder in adults who had never previously received treatment for a mood disorder (see story above).

The researchers randomly assigned 344 adults aged 18 to 65 with moderate MDD (mean baseline Hamilton Depression Rating Scale [HAM-D] score of 19.8) to 12 weeks of escitalopram (10-20 mg/day), duloxetine (30-60 mg/day), or cognitive-behavioral therapy (CBT, 16 50-minute sessions). Prior to randomization, patients indicated whether they preferred pharmacotherapy, CBT, or had no preference. Patients were evaluated at weeks 1 through 6, and again at weeks 8, 10, and 12.

The authors found that the mean estimated overall decreases in HAM-D score from baseline to week 12 did not significantly differ between treatments (CBT: 10.2; escitalopram: 11.1; duloxetine: 11.2). Additionally, remission rates did not significantly differ between treatment arms (CBT: 41.9 percent; escitalopram: 46.7 percent; duloxetine: 54.7 percent).

Of the 225 patients who expressed a treatment preference, 107 were matched to their preferred treatment and 118 were mismatched. Patients who were matched with their preferred treatment were significantly more likely to complete the trial than those who were not matched with preferred treatment (82.2 percent vs. 67.8 percent, respectively). However, patients matched to their preferred treatment were not found to be more likely to achieve remission.

“Asking patients about their treatment preference, and exploring the basis for their preference, can help build the therapeutic alliance, even if the clinician’s final treatment recommendation does not align with the patient’s preference,” Dunlop told Psychiatric News.

While the “findings about patients’ preferences do not warrant a change in current practice,” he said he believes advances in biomarkers will allow mental health professionals to “take a more definitive stance when recommending a specific form of treatment for an individual patient.”

The study was supported by the National Institutes of Health. ■