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Nonpharmacological Versus Pharmacological Treatments for Adult Patients With Major Depressive Disorder

Comparative Effectiveness Reviews, No. 161

Investigators: Gerald Gartlehner, MD, MPH, Bradley N Gaynes, MD, MPH, Halle R Amick, MSPH, Gary Asher, MD, MPH, Laura C Morgan, MA, Emmanuel Coker-Schwimmer, MPH, Catherine Forneris, PhD, ABPP, Erin Boland, BA, Linda J Lux, MPA, Susan Gaylord, PhD, Carla Bann, PhD, Christiane Barbara Pierl, PhD, MPH, and Kathleen N Lohr, PhD, MPhil, MA.

RTI International–University of North Carolina Evidence-based Practice Center
Rockville (MD): Agency for Healthcare Research and Quality (US); 2015 Dec.
Report No.: 15(16)-EHC031-EF
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Structured Abstract

Objective:

To compare the benefits and harms of second-generation antidepressants (SGAs), psychological, complementary and alternative medicine, and exercise treatment options as first-step interventions for adult outpatients with acute-phase major depressive disorder (MDD), and as second-step interventions for patients with MDD who did not achieve remission after a first treatment attempt with SGAs.

Data sources:

MEDLINE® (via PubMed®), Embase®, the Cochrane Library, AMED (Allied and Complementary Medicine Database), PsycINFO®, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) from January 1, 1990, through January 13, 2015.

Review method:

Two investigators independently selected, extracted data from, and rated risk of bias of studies. We graded strength of evidence based on established guidance.

Results:

Forty-four trials met inclusion criteria. For benefits across all interventions, we graded the strength of evidence as moderate for only one outcome of one comparison: SGAs compared with cognitive behavioral therapy (CBT). Results indicate that SGAs and CBT had similar effectiveness regarding symptomatic relief in patients with mild to severe MDD.

For risk of harms, we graded the strength of evidence as moderate for some outcomes of three comparisons—namely, SGAs compared with CBT, acupuncture, and St. John’s wort. Patients treated with SGAs had a higher risk of experiencing adverse events or discontinuing treatment because of adverse events than patients treated with CBT, acupuncture, or St. John’s wort.

Our confidence in the benefits and harms of SGAs compared with the remaining treatment options is low or insufficient, indicating that the bodies of evidence had major or unacceptable deficiencies. Nevertheless, for most comparisons, the overall findings indicated no statistically significant differences in benefits but a lower risk of adverse events for nonpharmacological treatment options. Across all comparisons of interventions, major research gaps pertain to information about the comparative risk of harms and patient-relevant outcomes such as functional capacity and quality of life.

For second-step therapies (i.e., therapy for patients with MDD who did not achieve remission after a first treatment attempt with SGAs), comparative evidence is limited. However, available data suggest that switching to another SGA, switching to cognitive therapy, and augmenting with a particular medication or cognitive therapy are all reasonable options.

Conclusions:

Overall, the available evidence indicates that SGAs and CBT do not differ significantly in symptomatic relief as first-step treatments for adult outpatients with moderate to severe MDD. SGAs, in general, lead to a higher risk of adverse events than nonpharmacological treatment options. The evidence is insufficient to form conclusions about differences in serious adverse events, such as suicidal ideas and behavior. Given comparable effectiveness, the choice of the initial treatment of MDD should consider results of previous treatments, patient preferences, and feasibility (e.g., costs, likely adherence, and availability) following a discussion of the advantages and disadvantages of each treatment option, including risks of particular adverse effects and potential drug interactions. Such shared and informed decisionmaking might enhance treatment adherence and improve treatment outcomes for patients with MDD, especially because treatment continuity is one of the main challenges in treating such patients.

Contents

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2012-00008-I, Prepared by: RTI International–University of North Carolina Evidence-based Practice Center, Research Triangle Park, NC

Suggested citation:

Gartlehner G, Gaynes BN, Amick HR, Asher G, Morgan LC, Coker-Schwimmer E, Forneris C, Boland E, Lux LJ, Gaylord S, Bann C, Pierl CB, Lohr KN. Nonpharmacological Versus Pharmacological Treatments for Adult Patients With Major Depressive Disorder. Comparative Effectiveness Review No. 161. (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2012-00008-I.) AHRQ Publication No. 15(16)-EHC031-EF. Rockville, MD: Agency for Healthcare Research and Quality; December 2015. www.effectivehealthcare.ahrq.gov/reports/final.cfm.

This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at www.effectivehealthcare.ahrq.gov. Search on the title of the report.

None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.

The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.

This report is made available to the public under the terms of a licensing agreement between the author and the Agency for Healthcare Research and Quality. This report may be used and reprinted without permission except those copyrighted materials that are clearly noted in the report. Further reproduction of those copyrighted materials is prohibited without the express permission of copyright holders.

AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.

This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at www.effectivehealthcare.ahrq.gov. Search on the title of the report.

Persons using assistive technology may not be able to fully access information in this report. For assistance contact vog.shh.qrha@eraChtlaeHevitceffE

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5600 Fishers Lane, Rockville, MD 20857; www​.ahrq.gov

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