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In Second Try to Treat Depression, Cognitive Therapy Generally As Effective As Medication

Science Update

Switching to or adding cognitive therapy (CT) after a first unsuccessful attempt at treating depression with an antidepressant medication is generally as effective as switching to or adding another medication, but remission may take longer to achieve. These results, which are part of the NIMH-funded Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, are published in the May 2007 issue of the American Journal of Psychiatry.

The STAR*D trial examined four levels of treatment for difficult-to-treat depression, all of which tested different medications and medication combinations. Results from the four levels of treatment involving medications are available here.

In Level 2, the 1,439 participants who did not become well while taking citalopram (Celexa) in Level 1 had the option of either switching to a new treatment (switch group) or continuing to take the citalopram while adding another treatment (add-on group). Those in the switch group had the option of trying either CT, a type of psychotherapy in which a person works to understand distortions in thinking and learn new ways of coping; or one of three antidepressants. Participants in the add-on group could add CT to their citalopram, or they could add a different antidepressant medication to their citalopram. Ultimately, 147 participants either switched to CT, or added it as an adjunctive treatment to citalopram.

Participants received up to 16 sessions of CT over 12 weeks. About 25 percent of those who switched to CT alone, and about 23 percent of those who added it, became symptom-free. The rates were not significantly different from those who were in medication-only treatment pathways in Level 2, suggesting that CT was generally as effective as medication as a second step in treating depression.

However, among those in the CT add-on group, remission took longer to achieve— an average of 55 days—compared with an average of 26 days among those who added another medication. The time to remission among the CT switch group was not statistically different from those who switched to another medication. But those who switched to CT were spared the side effects experienced by those who switched to another medication.

A second STAR*D-related paper by Stephen Wisniewski, PhD, and colleagues published in the same issue of the American Journal of Psychiatry examines the factors that affect participants’ willingness to accept switch or add-on treatment pathways. The paper also discusses the potential reasons why less than one-third of participants were willing to potentially take part in a treatment pathway that included CT.

Thase ME, et al. Cognitive Therapy as a Second-step Treatment: A STAR*D Report. American Journal of Psychiatry. 2007; 164.