In a randomized controlled trial, adding cognitive behavioral therapy or CBT to drug therapy was associated with a more than threefold increased likelihood of response to treatment after six months, Dr. Nicola Wiles of the University of Bristol in England and colleagues reported online in The Lancet.
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It is well recognized that only about a third of patients respond fully to antidepressants, but there's little evidence as to next-step treatment for these nonresponders, particularly with regard to CBT.
In one large trial, the STAR*D study, only 26 percent of patients were willing to be randomized to CBT as a second-step option, and that study focused on alternative treatment approaches, rather than looking specifically at whether the addition of CBT to drug therapy would improve depressive symptoms, the researchers said.
So they conducted the CoBalT trial, a parallel-group, multicenter, randomized controlled trial of 469 patients ages 18 to 75 from 73 general practices in the U.K. who'd had treatment-resistant depression. Patients received either their usual care, or CBT in addition to that usual care.
CBT involved at least 12 individual sessions lasting 50 to 60 minutes each, with a limit of 18 sessions.
The primary outcome was response, defined as at least a 50 percent reduction in depressive symptoms on the Beck Depression Inventory (BID) at six months. The vast majority of patients -- 90 percent -- were followed through that time, and 84 percent were tracked for a full year.
Almost three quarters of participants were women, the mean age of the entire cohort was 49.6 years, and 70 percent of patients had been on antidepressants for more than a year before being offered CBT.
Overall, Wiles and colleagues found that 46 percent of patients in the intervention group responded to therapy at six months, compared with 22 percent in the usual care group.
Those having CBT had better improvement in secondary outcomes at six months as well, they found. For instance, they were more likely to experience full remission at six months. They had fewer symptoms of anxiety and panic at that time, and greater improvements in the mental health as well, the researchers reported.
Wiles and colleagues concluded that CBT is a beneficial adjunct to antidepressant therapy in people who don't respond fully to the drugs. They warned, however, that in many countries, access to psychological treatment is often limited to people who can afford to pay for it.
Given that increasing the availability of CBT is difficult, they wrote, "greater investment in psychological services that deliver evidence-based therapies" is needed.
In an accompanying editorial, Dr. Michael Otto of Boston University and Dr. Stephen Wisniewski of the University of Pittsburgh said the study's high acceptance rates of CBT "stand apart from data" from STAR*D.
They called the findings "promising" and said they "add to the already impressive efficacy for CBT as assessed for other stages of treatment."
In addition, they wrote, if a new English program aimed at upping access to psychological therapies is funded and its broader vision realized, it "has the potential to serve as a model for depression treatment for other nations."