Cognitive behavioral therapy (CBT) alone proved to be superior to the combination of psychotherapy and antidepressant medication in the treatment of major depressive disorder (MDD) in a systematic review and meta-analysis published in Psychological Medicine.

Antidepressant medication is associated with side effects and withdrawal symptoms and 23% more expensive than psychological interventions, which patients often prefer. Evidence has also suggested that CBT and interpersonal psychotherapy (IPT) may be equally effective though little is known about comparisons of CBT and IPT, or either in combination with antidepressant medication.

Aoife Whiston, of the department of psychology, University of Limerick in Ireland, and colleagues conducted a literature search for articles investigating pre- and post-treatment in-person CBT or IPT in patients with MDD using PsycArticles, PsycINFO, PubMed, and Cochrane Library through December 2017. Statistical analyses included Cohen d index of individual effects, ANOVA subgroup analyses, and random-effects moderator meta-analyses.

The investigators identified 137 eligible studies that included 11,374 patients. In general, CBT (n=9375) and IPT (n=1999) were found to be equally effective, confirming prior evidence. Between-therapy moderator analyses showed comparable efficacy of CBT and IPT across age, gender, employment status, initial depression severity, comorbidities, number of previous episodes, therapy formats, therapy settings, and number of dropouts.

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However, in the case of psychotherapy delivered without concomitant antidepressants, CBT proved to be superior to IPT (P =.037), although this result did not remain significant in a Holm’s test correction. Furthermore, better clinical improvements were demonstrated with CBT alone than with concomitant antidepressants (P =.003). Within-CBT moderator analyses demonstrated that increased CBT efficacy was associated with younger age, greater initial severity of depression, individual administration format, and no concomitant use of antidepressants. In contrast, within-IPT analyses found comparable efficacy across all moderators.

The results of the analysis are limited by the high levels of heterogeneity in the studies included, such as the variability in the definition of the term CBT, as well as the failure to include recovery or remission rates in the analysis. Insufficient data on IPT studies may have also limited the ability of the researchers to identify moderators.

The researchers contend that “considering the superiority of CBT alone and the side-effects, tapering problems and withdrawal symptoms associated with [antidepressant medications], combined treatment should be prescribed carefully, only in complex cases and on a case-by-case basis.”

Reference

Whiston A, Bockting CLH, Semkovska M. Towards personalising treatment: a systematic review and meta-analysis of face-to-face efficacy moderators of cognitive-behavioral therapy and interpersonal psychotherapy for major depressive disorder. Psychol Med. 2019. doi:org/10.1017/S0033291719002812