Psychotherapy, Antidepressants, and Their ... - SAGE Journals

CanJPsychiatry 2013;58(7):386–392

In Review

Psychotherapy, Antidepressants, and Their Combination for Chronic Major Depressive Disorder: A Systematic Review Jan Spijker, MD, PhD1; Annemieke van Straten, PhD2; Claudi L H Bockting, PhD3; Jolanda A C Meeuwissen, MSc4; Anton J L M van Balkom, MD, PhD5 Director, Program for Mood Disorders Pro Persona, Mental Health Care, Nijmegen, the Netherlands; Professor of Chronic Depression, Behavioural Science Institute, Radboud University, Nijmegen and Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands. Correspondence: Netherlands Institute of Mental Health and Addiction (Trimbos Institute), PO Box 725, 3500 AS Utrecht, the Netherlands; [email protected].

1

Professor, Department of Clinical Psychology, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, the Netherlands.

2

Professor, Department of Clinical Psychology, Rijks Universiteit Groningen, Groningen, the Netherlands.

3

Senior Research Associate, Program Innovation of Mental Health, Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands.

4

Professor, Evidence-Based Psychiatry, Department of Psychiatry, EMGO Institute for Health and Care Research, VU University Medical Centre, and GGZ inGeest, Amsterdam, the Netherlands.

5

Key Words: chronic major depressive disorder, antidepressants, psychotherapy, systematic review Received June 2012, revised, and accepted October 2013.

Objective: Recommendations for treatment of chronic major depressive disorder (cMDD) are mostly based on clinical experiences and on the literature on treatment-resistant depression (TRD) but not on a systematic review of the literature. Method: We conducted a systematic review of 10 randomized controlled trials (RCTs), with 17 comparisons between antidepressants (ADs), psychotherapy, or the combination of both interventions. Results: The best evidence is for the combination of psychotherapy and ADs, and especially for the combination of the cognitive behavourial analysis system of psychotherapy and ADs. Evidence is very weak for both ADs alone and psychotherapy alone. Assessment of TRD was mostly absent in the studies. Conclusion: The best treatment for cMDD is a combination of psychotherapy and ADs. However, there is a lack of well-performed RCTs in both ADs and psychotherapy and their combination for cMDD. Therefore, the conclusions are preliminary. WWW

Psychothérapie, antidépresseurs, et leur combinaison pour le trouble dépressif majeur chronique : une revue systématique Objectif : Les recommandations de traitement du trouble dépressif majeur chronique (TDMc) sont principalement basées sur les expériences cliniques et la littérature sur la dépression réfractaire au traitement (DRT) mais pas sur une revue systématique de la littérature. Méthode : Nous avons mené une revue systématique de 10 essais randomisés contrôlés (ERC), ainsi que 17 comparaisons entre antidépresseurs (AD), psychothérapie, ou combinaison des deux interventions. Résultats : La meilleure évidence va à la combinaison de psychothérapie et AD, et spécialement à la combinaison du système d’analyse cognitivo-comportementale de la psychothérapie avec les AD. L’évidence est très faible pour les AD seuls et la psychothérapie seule. L’évaluation de la DRT était presque absente des études. Conclusion : Le meilleur traitement du TDMc est une combinaison de psychothérapie et d’AD. Cependant, les ERC bien menés sur les AD et la psychothérapie, et sur leur combinaison pour le TDMc, font défaut. Ces conclusions sont donc préliminaires.

386 W La Revue canadienne de psychiatrie, vol 58, no 7, juillet 2013

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Psychotherapy, Antidepressants, and Their Combination for Chronic Major Depressive Disorder: A Systematic Review

C

hronic major depressive disorder is a major public health problem owing to its high prevalence and great impact. In the general population, about 20% of people with MDE develop a chronic course1 and in depressed patients around 20% to 30% fulfill the criteria for chronicity.2,3 The 12-month prevalence of cMDD in the United States is 1.5%.4 In the DSM-IV,5 cMDD is classified as an MDD lasting more than 2 years, in which criteria for MDE are continually met. But also DD (that is, dysthymic disorder and an MDE) and recurrent depression without interepisodic recovery are considered as forms of cMDD. There is convincing evidence that there are more similarities than dissimilarities between these forms of cMDD.6 Moreover, there is reason to speculate that depressive disorders as a group can better be divided in acute and chronic forms.7 The consequences of a course of cMDD are serious, with an increased risk for suicidality,8 comorbidity with other psychiatric Axis I and II disorders, and increased disability in physical and psychosocial functioning.4

There is significant overlap between cMDD and TRD, although the terms are certainly not identical. Many people with cMDD have not been treated or have received inadequate treatment and therefore cannot be considered to have TRD. For instance, a study among 801 patients with cMDD who sought treatment in mental health care, revealed that only 33% had received an adequate trial of AD medication.9 The term TRD in itself is problematic because the definitions vary. Mostly it is expressed as the number of nonsuccessful biological treatments,10,11 thereby ruling out psychological treatment for cMDD. However, in most treated patients with cMDD, there is some form of TRD that complicates treatment. Therefore, clinicians and patients struggle with this condition, which many times endangers the therapeutic relationship because pessimism dominates the interaction.12 Abbreviations AD antidepressant BSP

brief supportive psychotherapy

CBASP cognitive behavourial analysis system of psychotherapy CBT

cognitive-behavourial therapy

CMA

Comprehensive Meta Analyses

DSM

Diagnostic and Statistical Manual of Mental Disorders

cMDD

chronic MDD

DD

double depression

ECT

electroconvulsive therapy

ES

effect size

IPT

interpersonal psychotherapy

MDD

major depressive disorder

MDE

major depressive episode

RCT

randomized controlled trial

TRD

treatment-resistant depression

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Clinical Implications •

The preferred treatment for patients with cMDD is a combination of ADs and psychotherapy, and probably CBASP is the psychotherapy of first choice although other psychotherapies may be as beneficial.

•

An assessment of TRD is necessary in all patients with cMDD.

Limitations •

We found a limited number of RCTs.

•

The studies were rather heterogeneous in design and quality.

There is a need to describe the therapeutic options for cMDD but former reviews on cMDD13–15 did not make a systematic evaluation of the literature. The most recent systematic review on chronic depression combined cMDD and dysthymia. This review was focused exclusively on psychotherapeutic interventions or the combination of psychotherapy and medication and omitted the pharmacological options.16 For this review, 16 studies were selected but 7 of them were exclusively aimed at patients with dysthymia. This review found psychotherapy less effective, compared with pharmacotherapy, and combination therapy superior to either monotherapy, but the results were largely attributable to the studies with only patients with dysthymia.16 Therefore, we will present a new systematic review of the literature on pharmacological and psychological interventions and their combination for cMDD. We excluded dysthymia but included DD and recurrent depression without interepisodic recovery in our definition of cMDD. We compare the results of our review on cMDD with the literature on TRD as these 2 conditions frequently co-occur.

Methods

For our review, we used the database on psychological treatment of depression.16,17 This database also includes studies on combined treatment and comparisons with pharmacotherapy.17 This database was developed through a comprehensive literature search (from 1996 to January 2012) in which 9011 abstracts were included from PubMed (1629 abstracts), PsycINFO (2439 abstracts), Embase (2606), and the Cochrane Central Register of Controlled Trials (2337). These abstracts were identified by combining terms indicative of psychological treatment and depression. Also the primary studies from 42 meta-analyses of psychological treatment for depression were included in the database. We did an extra literature search to also include papers on pharmacotherapy only. We used the search terms (major) unipolar depression, chronic, ADs, therapy, treatment, and the limits RCT, meta-analysis, systematic review and adults (18 to 65 years). Searches were performed in PsycINFO, MEDLINE, Cochrane, and Embase databases until September 2011. In addition, the reference lists of all included studies were searched for other relevant studies. The Canadian Journal of Psychiatry, Vol 58, No 7, July 2013 W 387

In Review

For our study, we included the studies on psychological, pharmacological, and combined treatment in adults (>18 years of age) with a diagnosis of cMDD that was established with a diagnostic interview. The studies were RCTs, and compared the effect of the intervention to a control group, another active treatment, or a combined treatment. Studies on adolescent and children were excluded. Comorbidity with somatic or psychiatric disorders was not used as an exclusion criterion. We recorded major characteristics of the selected studies as characteristics of the target group (age, percentage of women, percentage married), the definition of cMDD, recruitment method, type of treatment, exclusion criteria (anxiety disorders, substance-related disorders, personality disorders), type of treatment (medication, psychotherapy, combination), country where the study was conducted, and whether the study was conducted in a subsample of a larger study or not. Information on TRD of the index MDE (if present) was also recorded. We assessed validity of the included studies using numerous basic criteria: allocation to conditions conducted by an independent (third) party, blinding of the assessors of outcome, and completeness of follow-up data. We only checked for the adequacy of randomization concealment in the medication studies as it is not possible in the psychotherapy studies to conceal the randomization to the patients. All effects between the intervention and control group (or another active treatment) were expressed as the standardized difference between the 2 groups (Hedges g). All ESs were calculated in CMA. CMA can handle data in different formats (for example, mean scores on posttest as well as percentage improved) and convert them to Hedges d. ESs of 0.8 can be assumed to be large, while ESs of 0.5 are moderate and ESs of 0.2 are small.18

Results Characteristics of the Included Studies

Seven studies from the database met our inclusion criteria, and in the additional search for pharmacological treatment 3 more studies were found. Thus, in total, we selected 10 studies; 3 studies on pharmacologic treatment of cMDD,19–21 3 studies on psychotherapy,22–24 and 4 on combination treatment.25–29 In total, 2316 patients were included in the studies. Selected characteristics of the studies are presented online in eTable 1. Four studies included patients with cMDD, DD, and recurrent MDD without interepisodic recovery, 2 on cMDD and DD; 1 on cMDD, DD, and some dysthymic patients, 1 on cMDD and recurrent MDD without inter-episodic recovery, and 2 on cMDD only. Eight studies were aimed at adult depressed outpatients, and only one focused on inpatients. In most studies females were overrepresented and the mean age was mostly over 40 years. Information on TRD was presented in only 2 studies; 2 other studies used TRD as an exclusion criterion. The number of sessions varied between 388 W La Revue canadienne de psychiatrie, vol 58, no 7, juillet 2013

11 and 24 for the psychotherapy studies, and mostly the therapy had an individual basis. In one study, the Inventory for Depressive Symptomatology was used to calculate ESs, in the other studies, the Hamilton Depression Rating Scale. Three studies were a subsample of a larger trial.

Quality of the Studies

The quality of the included studies varied. Blinding of the assessors was reported in 3 studies; only the 3 AD studies used a double-blind design. In 5 studies, randomization was centrally organized by a computer program. In the other studies, no information was given on the randomization procedure. Intention-to-treat analyses were conducted in 6 studies, and 2 studies reported the completers-only analyses. In the remaining 2 studies it was not clear how missing data were handled. The quality of the treatment implementation in the studies was good: in all studies the therapist were trained for the therapy; in 6 studies a treatment manual was used, and in 7 studies the integrity of the treatment was checked during the study.

Interventions

Because of the design of 3 of the selected studies, more than 10 comparisons could be made between different treatment conditions, resulting in total 17 comparisons (Table 2). AD Treatment Only one comparison between AD treatment and placebo was found. This was the Agosti and Ocepek-Welikson study,22 which was part of the National Institute of Mental Health Treatment of Depression Collaborative Research Program, a placebo-controlled study of psychotherapy for outpatients with unipolar depression.30 In a subsample of 20 patients with cMDD, with a mean duration of depression of 15.9 years (SD 7.9), imipramine was not more effective than placebo (ES = –0.11; not significant). In a small study with 48 patients with cMDD,19 fluoxetine was compared with clomipramine and there was not a significant difference between the 2 ADs (ES = 0). The other 2 comparisons on pharmacological treatment of cMDD came from the same study: an RCT on AD treatment in 635 patients with chronic depression (294 with cMDD and 341 with DD), who were randomized to 12 weeks acute treatment with either sertraline or imipramine.20 Remission rates were 36% for sertraline and 40% for imipramine and not significantly different, resulting in an ES of 0.02. Further, there were no differences in remission rates between the patients with cMDD and those with DD. In the follow-up, 168 patients who had not responded to sertraline or imipramine were switched to the other AD.21 The differences in remission rates were as follows: 32% in the sertraline group and 23% in the imipramine group, resulting in an ES of 0.27, favouring sertraline (not significant). Psychotherapeutic Treatment The psychotherapies in the selected studies were CBT, IPT, BSP, and CBASP. CBASP is an individual-based form of psychotherapy especially developed for cMDD.31 www.LaRCP.ca


Table 2 Comparisons for ADs, psychotherapy, and combination therapy for cMDD Study

Intervention

N

Mean (SD) end point

Control

N

Mean (SD) end point

g

95% CI

Agosti and OcepekWelikson22

Imipramine

20

10.3 (7.7)

Placebo

15

9.5 (5.7)

–0.11

–0.77 to 0.54

Aguglia et al19

Fluoxetine

24

14.3

Clomipramine

24

12.3

0

–0.65 to 0.65

Keller et al20

Sertraline

426

13.6

Imipramine

209

14.1

0.02

–0.16 to 0.21

Thase et al

Imipramine

117

15.3 (9.4)

Sertraline

50

12.8 (8.4)

0.27

–0.06 to 0.60


CBT

16

9.5 (7.2)

Placebo

15

9.5 (5.7)

0

–0.69 to 0.69


IPT

14

10.3 (8.4)

Placebo

15

9.5 (5.7)

–0.11

–0.82 to 0.60

Harpin et al23

CBT

6

16.3 (14.6)

Wait-list

6

23.3 (10.0)

0.52

–0.55 to 1.58

21

CBASP

14

11.21 (10.84)

IPT

15

18.87 (11.71)

0.66

–0.07 to 1.39


CBT

16

9.5

Imipramine

20

10.3 (7.7)

0.10

–0.54 to 0.75


IPT

14

10.3 (8.4)

Imipramine

20

10.3 (7.7)

0

–0.67 to 0.67

Schramm et al

24

CBASP

220

14.7 (10.38)

Nefazodone

216

15.1 (10.14)

–0.04

–0.15 to 0.23

IPT + AD

24

9.95 (7.44)

AD + clinical management

21

14.05 (7.93)

0.53

–0.06 to 1.11

Keller et al25

CBASP + nefazodone

220

14.7 (10.38)

Nefazodone

226

9.7 (9.77)

0.50

0.31 to 0.68

Kocsis et al27

AD + psychotherapy

94

12.28 (8.44)

AD

384

12.02 (8.39)

0.03

–0.28 to 0.22

Keller et al25

CBASP + nefazodone

216

15.1 (10.14)

CBASP

226

9.7 (0.7)

0.54

0.35 to 0.73

Kocsis et al27

AD + CBASP

189

12.77 (8.45)

AD + BSP

195

11.29 (8.30)

0.18

–0.03 to 0.38

Wiersma

AD + CBASP

69

23.1 (13.6)

AD + CAU

73

33.2 (13.9)

0.73

0.33 to 1.13

Keller et al25 Schramm et al26

29

CAU = care as usual

In the before-mentioned study of Agosti and OcepekWelikson,22 response rates of CBT, compared with placebo (N = 16), and IPT, compared with placebo (N = 14), were not significantly different, resulting in an ES of 0 for CBT and –0.11 for IPT. In the study of Harpin et al,23 12 patients with cMDD (mean duration of depression was 17.8 years) were randomized to CBT during 10 weeks or wait-list control. There was a moderate effect for CBT (ES = 0.52), although not significant. Only one recent study directly compared 2 forms of psychotherapy. In this trial of 29 patients with cMDD, CBASP was more effective than IPT after 16 weeks of acute phase treatment, with an ES of 0.66, but this effect was not significant.24

nefazodone and the combination of both during 12 weeks.25 Nefazadone and CBASP were almost equally effective (ES = 0.04; nonsignificant).

Psychotherapeutic Treatment, Compared With AD Treatment In 3 studies, psychotherapy was compared with pharmacotherapy. In the study of Agosti and Ocepek-Welikson,22 CBT and IPT, compared with imipramine, were studied in patients with cMDD, resulting in nonsignificant ESs of 0.10 for CBT and 0 for IPT. In a third study with 681 patients with cMDD, DD, and recurrent depression with incomplete interepisodic recovery, CBASP was compared with the AD

In the study by Keller et al,25 a moderate and significant effect was found for combination treatment of CBASP and nefazodone, compared with nefazodone alone (ES = 0.50). In the study by Kocsis et al,27 491 patients with cMDD, who did not respond to AD treatment during 12 weeks, were randomized to combined treatment of CBASP and ADs, compared with BSP and ADs, compared with continuation of AD treatment alone in optimal dosing, all during another 12 weeks. The combination of psychotherapy (CBASP

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Combination of Psychotherapy and AD Treatment, Compared With AD Treatment The combination of psychotherapy and ADs for cMDD was compared with pharmacotherapy in 1 study with 45 inpatients with cMDD. They were randomized to either a clinical IPT program plus pharmacotherapy or the control condition with clinical management, including pharmacotherapy. There was a moderate effect for IPT plus pharmacotherapy (ES = 0.53) although not significant.26

The Canadian Journal of Psychiatry, Vol 58, No 7, July 2013 W 389

In Review

and BSP) and ADs was not more effective than ADs alone (ES = 0.03). Combination of Psychotherapy and ADs, Compared With Psychotherapeutic Treatment Only one comparison was found: in the Keller et al study,25 a moderate and significant effect was found for combination treatment of CBASP and nefazodone, compared with CBASP alone (ES = 0.54). Combination of Psychotherapy and ADs, Compared With Combination of Psychotherapy and ADs In the study by Kocsis et al,27 a small, not significant effect was found for the combination of CBASP and ADs, compared with BSP and ADs (ES = 0.18). Finally, Wiersma et al28,29 randomized 142 patients with cMDD, DD, and recurrent depression with incomplete interepisodic recovery to CBASP and ADs or care as usual (other forms of psychotherapy and ADs) during 52 weeks. The combination with CBASP yielded a great and significant effect (ES = 0.73) in a completers-only analysis, but only during a 1-year follow-up period.

Conclusion

Unfortunately, the literature on treatment options for cMDD is limited. We found only 4 comparisons on AD treatment of cMDD, 4 on psychotherapy, 4 that compared psychotherapy to pharmacotherapy, and 6 on combination therapy. Most of the studies included DD and (or) recurrent depression without interepisodic recovery in their definition of cMDD. The information on TRD of cMDD in these studies was largely absent or TRD was used as an exclusion criterion. Despite this meagre outcome, some evidence appears form this review of the literature. The evidence for AD treatment for cMDD is very weak. There is only one placebo-controlled trial with a negative outcome. However, this was a very small study. In direct comparisons between ADs, there were no differences between ADs or only a small advantage for the selective serotonin reuptake inhibitor sertraline, compared the tricyclic AD imipramine. These findings are neither in line with the extensive literature on AD treatment of TRD nor with clinical practice. ADs are widely used as therapeutic monotherapy for patients with cMDD. There is ample evidence for the efficacy of ADs in case of TRD.32–34 Most reviews suggest an AD algorithm with consecutive medication steps, including augmenting and combining strategies.35,36 In clinical practice, many patients with cMDD are also treatment resistant and therefore the recommendations about how to treat TRD in the guidelines for MDD37,38 seem to be applicable in the treatment of cMDD. But strictly speaking, we must conclude that there is a lack of evidence for using ADs in patients with cMDD. Unfortunately, the evidence for psychotherapeutic interventions for cMDD is also not convincing. From the 4 studies on psychotherapy for cMDD that we found, 2 390 W La Revue canadienne de psychiatrie, vol 58, no 7, juillet 2013

were negative, 1 found a positive though not a significant effect, and 1 demonstrated superiority for CBASP over IPT. However, all studies were very small. Not surprisingly, no differences were found in direct comparisons between psychotherapy and ADs, and also not in the adequately performed and large study of Keller et al.25 Although, in view of the paucity of studies, definitive conclusions are very premature, it is striking that the limited effects of ADs and psychotherapy for cMDD are in sharp contrast with the well-established positive effects of both interventions in nonchronic MDD,39,40 albeit that these treatments effects are overestimated owing to publication bias.40,41 The results of this review lend support to the notion that, in general, treatment effects in cMDD are smaller, compared with those in nonchronic MDD. Interestingly, this effect was indeed found for psychotherapy in dysthymia,16 another form of chronic depression, but the efficacy of ADs in dysthymia is well established.42 Although in the DSM-5, chronic depressive disorder is proposed as a combination of dysthymic disorder and cMDD, the conclusion of our review lends some support for the idea that the treatment effect for ADs differs between patients with dysthymic disorder and cMDD. It is possible that TRD also is at stake in this respect and that studies that included dysthymic patients did not select many patients with TRD in contrast to studies of patients with cMDD. The best evidence from the selected studies comes for the combination of psychotherapy and ADs, and more precisely for the combination of CBASP and ADs. Moderate-to-large and significant effects were found for this combination in 2 studies. The pioneering study of Keller et al25 found the combination of nefazodone and CBASP superior to both nefazodone and CBASP alone. The superiority of CBASP plus medication was partially replicated in a recent study of Wiersma.29 However, the last study reported completersonly analyses and superiority of CBASP and medication only appeared toward the end of this long-term study (1 year). Further, superiority of the CBASP and ADs combination was not demonstrated in the study by Koscis et al27 after a treatment period of 12 weeks. Thus there is conflicting evidence regarding CBASP combination therapy. The combination of IPT and ADs was also favourable in depressed inpatients.26 Combination treatment is probably better, no matter what kind of psychotherapy. However, in a direct comparison between CBASP and IPT, CBASP was superior,24 giving more credits to the combination of CBASP and medication. There are several limitations to our review. First, the paucity of the studies limits any definitive conclusions on the optimal treatment for cMDD. Especially, there are too little studies on monotherapy with either ADs or psychotherapy. Second, the 10 studies differed in many aspects as characteristics of the patients, seize, in- and exclusion criteria, intervention, duration, and quality of the study. Therefore, it was not possible to meta-analyze the effects and we could only provide ESs for each separate study. Even these ESs must be compared with great caution. www.LaRCP.ca


Third, most studies included patients with DD or recurrent depression without interepisodic recovery and even some dysthymic patients26 in the inclusion criteria. There seem to be some differences in treatment effects in dysthymic patients, compared with patients with cMDD, but it is yet unknown if there are also differences between the variants of chronic major depression (that is, cMDD, DD, recurrent depression without interepisodic recovery). Fourth, information on TRD was mostly absent, and, interestingly, the study with the largest ESs for the combination therapy25 had excluded TRD. It is important that TRD is assessed and reported in each study in the treatment of depression but especially in studies in cMDD it seems mandatory. In conclusion, the evidence for any therapeutic intervention for cMDD is very limited. Psychotherapy in combination with AD medication may be beneficial for cMDD. CBASP may be a promising treatment for cMDD, though evidence is momentarily rather mixed. The most recent study indicates that psychotherapy in cMDD may take longer before it produces change in symptomatology.29 Our results are in close agreement with other systematic reviews and meta-analyses that found combination treatment superior for depression,40 and especially in the more severe, recurrent, or chronic depression.43–45 Still, there is an urgent need for more high-quality RCTs for combination therapy with the available ADs and psychotherapies, with adequate randomization procedures, blinding of the assessors, and the inclusion of all randomized respondents in the final analysis. Important research questions include the following: What is the most cost-effective combination therapy? What intensity of treatment is needed? What is the optimal duration of the combination? And, what are the long-term benefits of combination therapy? Further, not all patients can profit from psychotherapeutic interventions, and alternatives for combination therapy must be developed, especially biological interventions like repetitive transcranial magnetic stimulation.46 There is, of course, a biological option: ECT with good evidence for efficacy in severe, psychotic, and TRD47; however, ECT has not been studied adequately for patients with cMDD, and further, it may not be acceptable for many patients with cMDD. Because cMDD is a very complex and, by nature, persistent condition it is unrealistic to expect recovery from a single intervention or even combination of 2 interventions. Therefore, care for cMDD should be organized in a way that multiple, successive treatment and rehabilitation interventions can be applied to reach and maintain longterm symptomatic and functional improvement. Disease management programs are most suitable for that goal and have proven to be effective.15,48,49 The burden of disease in cMDD is immense and justifies intensive and prolonged treatment efforts.

Acknowledgements

Dr Spijker has been on speakers’ bureaus for AstraZeneca, Eli Lilly, GlaxoSmithKline, Lundbeck, and Servier. www.TheCJP.ca

The Canadian Psychiatric Association proudly supports the In Review series by providing an honorarium to the authors.

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