The American College of Physicians (ACP) reports major depressive disorder (MDD) is the most prevalent depressive disorder in the United States, with an estimated lifetime prevalence of 16 percent. MDD patients are frequently treated by their primary physician, who tend to prescribe second-generation antidepressants (SGAs) like selective serotonin reuptake inhibitors. While effective, a new study suggests cognitive behavioral therapy (CBT) should be considered for patient care.

"Patients are frequently treated for depression by primary care physicians, who often initially prescribe SGAs," said Dr. Wayne J. Riley, ACP president, in a press release. "However, CBT is a reasonable approach for initial treatment and should be strongly considered as an alternative treatment to SGAs where available, and after discussing treatment effects, adverse effect profiles, costs, accessibility, and preferences with patients." The ACP's study is now available in the Annals of Internal Medicine.

Riley and his co-authors conducted a systematic evidence review of several studies on the efficacy of depression-focused psychotherapy, complementary and alternative medicine, exercise, and SGAs. They also analyzed treatment outcomes, such as relapse, quality of life, functional capacity, and reduced risks for suicide and hospitalization.

The study authors categorized evidence as low, moderate, or high quality. An example of low-quality evidence would be that St. John’s Wort, an herbal supplement, is as effective as SGAs. The quality of evidence determines the strength (strong or weak) of the ACP’s recommendations. So if the benefits clearly outweigh the risks and burden, then it gets a strong recommendation. If the burden outweighs the benefits, it gets a weak recommendation. Authors also measured if the benefits were finely balanced with regard to risk and burden.

The authors found low-quality evidence showed no difference in effectiveness or adverse effects between first-line pharmacologic (SGAs) or non-pharmacologic (complement medicine, exercise, and combination therapies) treatments in patients with MDD. The moderate-quality evidence, on the other hand, showed that SGAs and CBT are similarly effective treatments with similar discontinuation rates.

Adverse effects are one reason for discontinuation, with some of the most commonly reported effects being constipation, diarrhea, dizziness, headache, and insomnia. Other studies report antidepressant drugs can sometimes increase risk for suicide. It's important to note, however, some antidepressants come with fewer side effects than others, and that they're generally found to be safe and effective.

"Moderate-quality evidence suggests that discontinuation rates are similar for CBT and SGAs, although discontinuation due to adverse events is non-statistically significantly increased with SGAs," the authors wrote. "However, harms associated with SGAs are probably underrepresented in the included trials. Thus, we conclude that CBT has no more — and probably fewer — adverse effects than SGAs."

It's the ACP's official recommendation, then, that clinicians select between either CBT or SGAs to treat patients with MDD after they have discussed treatment effects, potential for adverse effects, cost, accessibility, and the patient's general preference.

"The [ACP] feels very strongly that the treatment of major depressive disorder is an important aspect of primary care practice, and that it's often undertreated or underappreciated by patients and physicians alike," Riley said. "Addressing it will ultimately lead to a healthier population."

Source: Qaseem A, Barry MJ, Kansagara D. Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients With Major Depressive Disorder: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine. 2016.