Depression: Talk sooner, pill later

4. April 2013
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Whoever goes to a doctor for depression is quickly provided with antidepressants. Yet is that good? Researchers have now found that it is often more helpful in cases of mild depression to begin with psychodynamic therapy.

Fatigue, dejectedness, insomnia, loss of appetite and brooding – if these depressive symptoms last for more than two weeks, according to guidelines treatment is then indicated. About 15% of women and 8% of men within 12 months of that point are diagnosed as having depression (IQWiGReport 2009, No. 34). Physicians do indeed treat patients individually, but many initially prescribe antidepressants. Jack Dekker and his colleagues at the Arkin Institute of Mental Health, Amsterdam, wondered how a doctor can best proceed: first psychotherapy and then tablets, or vice versa?

The Dutch researchers conducted a study involving 103 patients suffering from mild or moderate depression. Patients were randomised into two treatment arms: one group was initially given psychodynamic therapy, the other group initially received antidepressants. If the symptoms had not improved within eight weeks by at least 30%, the patient was offered a combined therapy. The interesting thing: even when the initial treatment had not struck the mark, 40% of patients wanted to continue their monotherapy.

In order to put down the symptoms the authors used the Hamilton Depression Scale (HAM-D) and the Clinical Global Impression Scale (CGI). They also used the Depression Subscale of the Symptom Checklist SCL-90 as well as the Euro-Quality of Life Questionnaire (EuroQol).

The results showed: at the end of the study the condition of the patient who had first received psychodynamic therapy had improved more than the condition of the patients initially treated with medication. The authors conclude that it is useful to offer psychotherapy to patients with mild or moderate depression and only bring in medication additionally where there is no improvement.

Early improvement helps

Particularly important for the success of treatment apparently is experience of success with the therapy – this is what one study done by psychologist Amrei Schindler and her colleagues at the University of Mainz finds, among others. The scientists wanted to know which factors contribute to successful behavioral therapy, and at which point patients break their treatment. For this purpose they studied 193 patients who were suffering unipolar depression or dysthymia. The patients received cognitive-behavioral therapy (CBT). A good response to therapy could then be expected when the patient prior to treatment had shown more severe depression, and already early in therapy felt an improvement in symptoms. An interruption was likely when the patients indicated having a personality disorder, had lower expectations for the therapy and felt no improvement at an early stage of therapy.

Conclusion

With depressive patients a lot of discretion is warranted in the initiation of treatment. Mild and moderate depression can be treated initially with a psychodynamic therapy – only in the instance of non-response should the physician also provide drug therapy. Astonishingly, many patients prefer monotherapy, as the Jack Decker et al. study shows. Cognitive-behavioral therapy is also effective, apparently early therapeutic success is crucial for a good outcome.

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