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Evidence Summary

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In people with major depression who haven’t been treated before, there are several equally effective treatment options

Gartlehner G, Gaynes BN, Amick HR, et al. Comparative Benefits and Harms of Antidepressants, Psychological, Complementary, and Exercise Treatments for Major Depression: An Evidence Report for a Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016;164:331-41.

Review question

In people with major depression who haven’t been treated before, are antidepressant drugs any better or worse than other therapies?

Background

Depression is a common mood disorder that affects how you feel, think, and behave. It may be mild or more severe and persistent (major depression). Symptoms include feeling sad, losing interest in things you like to do, having trouble thinking or concentrating, or feeling anxious or restless.

Depression is more than just being sad and may get worse if not treated. There are many treatments for depression including drugs, psychotherapies, and other treatments (e.g., exercise, acupuncture, supplements).

The research

45 studies (randomized controlled trials) that were published up to September 2015.

The studies included outpatients who had a diagnosis of major depressive disorder. Most were women with an average age of about 35 to 45 years.

Studies compared antidepressant drugs (mostly fluoxetine, sertraline, paroxetine, venlafaxine, citalopram, or escitalopram) with other therapies, including psychotherapies (mainly cognitive-behavioural therapy [CBT] or interpersonal psychotherapy), St. John’s wort, acupuncture, exercise, omega-3 fatty acid supplements, or S-adenosyl-L-methionine (SAMe) supplements.

Therapies lasted for at least 6 weeks, and most studies treated people for 12 weeks or less.

What the researchers found

Compared with antidepressant drugs:

  • CBT and St. John’s wort reduced depression in about the same number of people at up to 16 weeks of therapy;
  • fewer people using St. John’s wort stopped therapy because of an adverse event; and
  • about the same number of people having CBT stopped therapy because of an adverse event.

We don’t have enough information about how well other therapies work compared with antidepressant drugs.

Conclusion

In people with major depression who haven’t been treated before, antidepressant drugs, cognitive-behavioural therapy, or St. John’s wort work about equally well.

Antidepressant drugs vs other therapies in people with major depression who haven’t been treated before

Comparisons

Outcomes

Number of trials and people

Outcome rate with antidepressant drugs

Outcome rate with other therapy

Absolute effect of antidepressant drugs

Antidepressant drugs vs CBT

Response rate

5 trials (660 people)

44%

46%

No difference in effect at 8 to 16 weeks*

 

Stopped treatment because of adverse events

3 trials (441 people)

8%

3%

No difference in effect*

Antidepressant drugs vs St. John’s wort

Response rate

9 trials (1,517 people)

52%

54%

No difference in effect at 6 to 12 weeks*

 

Stopped treatment because of adverse events

9 trials (1,651 people)

7%

4%

About 3 more people out of 100 stopped therapy because of an adverse event (from as few as 1 to as many 6 out of 100)

CBT = cognitive-behavioural therapy.

*Although the rates for the 2 groups look a little different, the differences were not statistically significant. This means that the differences could simply be due to chance rather than due to the different therapies.




Glossary

Randomized controlled trials
Studies where people are assigned to one of the treatments purely by chance.

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