Fighting chronic
depression: Two therapies better than one
BY CAROLINE SEYDEL
Conventional wisdom among
psychiatrists has dictated that people suffering from
chronic depression are best treated with a combination of
antidepressants and psychotherapy. Now, a large national
study confirms that combination therapy is more effective
than either medication or counseling alone.
The study, published May
18 in the New England Journal of Medicine, shows that the
antidepressant nefazodone hydrochloride (Serzone)
combined with psychotherapy specifically designed for
chronic depression offers the best treatment for people
suffering from this long-term form of depression.
This study is the largest
ever undertaken comparing medication alone, psychotherapy
alone, or combination treatment for chronic depression,
according to the researchers. Bristol-Myers Squibb Co.,
makers of Serzone, funded the research.
"This is the first
study that's been large enough to adequately test whether
combination treatment is truly superior to medication or
psychotherapy alone," said study co-author Bruce
Arnow, PhD, assistant professor of psychiatry and
behavioral sciences at Stanford.
In the study, 681
depressed patients were randomly assigned to one of three
treatment options. Patients assigned to the drug-only
group took nefazodone alone, therapy-only patients
received psychotherapy tailored to chronic depression,
and combination patients were given both simultaneously.
After 12 weeks, significantly more patients who received
the combination of therapies had improved compared with
patients receiving either single treatment.
At any given time, 3
percent of the U.S. population suffers from chronic
depression. Chronically depressed individuals are
hospitalized more often, require more health care, and
attempt suicide more frequently than those suffering from
episodic depression. They have more severe problems with
work, family and social relationships. In their paper,
the researchers assert that "chronic depression
accounts for an inordinate portion of the enormous
illness burden associated with depression."
"It's a major public
health problem in this country," Arnow said,
"and this [study] sheds important light on the most
appropriate treatment for this group of patients."
Study participants
included adult men and women of varying ages who scored
20 or greater on the Hamilton Rating Scale for Depression
(HAM-D). The HAM-D assesses the severity of depression in
patients who are already diagnosed with depression. The
higher the score, the more severe the depression. A score
of below 8 is considered normal; the average score of
patients at the start of the study was 27.
Among patients who
completed 12 weeks of combination therapy, 85 percent
reduced their HAM-D score by at least half. For both
drug-only and therapy-only patients, only about 50
percent reduced their score by that much.
"Patients in this
study had been suffering major depression for an average
of eight years," Arnow noted. "Many had been
suffering for 20 years or more, so the response to
combination treatment of 12 weeks is very striking."
The psychotherapy used in
the study, Cognitive Behavioral Analysis System of
Psychotherapy, or CBASP, is the first psychotherapy
developed specifically to treat chronic depression. It
teaches patients to focus on how their thinking and
behavior affect their interpersonal interactions and to
apply a specific problem-solving technique to improve
their functioning in interpersonal situations.
Few therapists are trained
in CBASP, however, and Arnow hopes the results of this
study will spur efforts to provide psychotherapists with
more opportunities to learn it, making it more widely
available.
The antidepressant
studied, used alone or in combination with psychotherapy,
was associated with an earlier response than
psychotherapy alone. Patients did not experience
significant sexual dysfunction or weight gain, both
common side effects of antidepressant medications.
The results for both
single treatments were comparable to those found for
antidepressants in prior studies of patients with chronic
depression. However, Arnow noted, the results of the
current study cannot be generalized to other
antidepressants used in combination with psychotherapy or
forms of psychotherapy other than CBASP until they have
been tested in clinical trials and shown similar response
rates.
The study also included a
four-month continuation trial for patients who responded
to medication alone, psychotherapy alone or combination
treatment. This was followed by a 52-week maintenance
phase evaluating either the drug versus placebo or
monthly psychotherapy. The data from these two phases are
still being evaluated.
A key strength of the
study is that researchers at all sites found the same
results, Arnow said. "The fact that the pattern of
results didn't vary from site to site makes the findings
all the more compelling."
In addition to Arnow,
contributing researchers at Stanford include Alan
Schatzberg, MD, professor and chair of psychiatry and
behavioral science; Rachel Manber, MD, assistant
professor of psychiatry and behavioral science; and
Lorrin Koran, MD, professor of psychiatry and behavioral
science.
Other study sites included
Brown University; Medical College of Virginia &
Virginia Commonwealth University; State University of New
York, Stonybrook; Cornell University Medical College;
Emory University School of Medicine; University of Texas
Medical Branch at Galveston; University of Texas
Southwestern Medical Center at Dallas;
Rush-Presbyterian-St. Luke's Medical Center, Chicago;
University of Washington, Seattle; University of Arizona,
Tucson; and Western Psychiatric Institution and Clinic,
University of Pittsburgh.
Many of the principal
investigators were consultants and received honorariums
from Bristol-Myers Squibb or serve on the company's
scientific advisory board. Most also have similar
relationships with other firms that manufacture
FDA-approved treatments for depression. SR
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