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Depression treatment 'should be based on patient preference'

GPs should base their treatment decisions in depression on patient preference, as there are few significant differences between the various types of therapies recommended in guidelines, concludes a new analysis.

The systematic review into the efficacy of treatments for depression found antidepressants and psychotherapy showed no significant difference in the reduction of depression symptoms compared with alternative therapies, such as acupuncture or exercise.

The US researchers concluded the type of treatment GPs offered patients with depression was ‘less important than getting involved in an active therapeutic programme'.

NICE guidelines currently recommend a stepped approach to care, with antidepressant medication and psychological interventions suggested for mild to moderate depression or worse.

The authors looked at 115 trials into a total of 10,310 patients with depression aged between 18 and 65 years that looked at drug treatment, psychotherapy – including cognitive behavioural therapy – or alternative therapies, and compared them with controls, usual care or placebo. The antidepressant data came from trials that were reviewed by the US Food and Drug Administration as part of the drug approval process.

They found all interventions studied resulted in significant reductions in depression symptoms compared with placebo, usual treatment and waiting-list controls.

A combination of antidepressant medication and psychotherapy had the greatest impact in reducing depression symptoms – a 52% reduction compared with before the intervention. This change was significantly better than antidepressant therapy alone, psychotherapy alone and alternative therapy, which recorded 46%, 47% and 47% reductions respectively compared with before intervention.

But antidepressants alone, psychotherapy alone, alternative therapies and active intervention controls showed no significant differences when compared with each other in the analysis, leading the to authors question whether the type of treatment offered was relevant.

The study authors, from Duke University School of Medicine in the US, concluded: ‘These data suggest the preference of the patient, accessibility of various treatment options and riskiness of the therapy should be factored into depression treatment decisions. It is important to note that engaging in treatment is critical to improvement.'

But Professor Helen Lester, a GP in Birmingham and RCGP mental health commissioning lead, warned GPs should exercise ‘caution' about changing their clinical decisions based on this evidence.

She said: ‘There are problems with the data used to draw the conclusion, which the authors do point out in the paper. They did not evaluate the role severity of depression may have played in treatment outcome, and we know that in other studies treatment efficacy has been linked with just how depressed someone is.'

PLoS One2012, online 30 July

 

Percentage reduction in depression symptoms

  • Combination therapy: 52%
  • Antidepressants: 46%
  • Psychotherapy: 47%
  • Alternative therapy: 47%

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