BMJ 2001;322:772 ( 31 March )

Primary care

Antidepressant drugs and generic counselling for treatment of major depression in primary care: randomised trial with patient preference arms

Clair Chilvers, professor, a Michael Dewey, senior lecturer, a Katherine Fielding, lecturer, a Virginia Gretton, research assistant, a Paul Miller, lecturer in health economics, a Ben Palmer, research associate, a David Weller, professor, c Richard Churchill, lecturer, b Idris Williams, professor, b Navjot Bedi, specialist registrar in psychiatry, d Conor Duggan, professor, e Alan Lee, consultant psychiatrist and special senior lecturer, f Glynn Harrison, professor, g for the Counselling versus Antidepressants in Primary Care Study Group.

a Trent Institute for Health Services Research, University of Nottingham Medical School, Queen's Medical Centre, Nottingham NG7 2UH, b Division of General Practice, University of Nottingham Medical School, Queen's Medical Centre, c Department of General Practice, University of Edinburgh, 20 West Richmond St, Edinburgh EH8 9DX, d Division of Psychiatry, Nottingham Healthcare NHS Trust, Nottingham NG3 6AA, e Division of Forensic Mental Health, University of Leicester, Arnold Lodge, Leicester LE5 0LE, f Department of Psychiatry, University Hospital, Queen's Medical Centre, g Division of Psychiatry, University of Bristol, Bristol BS2 8DZ

Correspondence to: C Chilvers Clair.Chilvers{at}doh.gsi.gov.uk

Objectives: To compare the efficacy of antidepressant drugs and generic counselling for treating mild to moderate depression in general practice. To determine whether the outcomes were similar for patients with randomly allocated treatment and those expressing a treatment preference.
Design: Randomised controlled trial, with patient preference arms. Follow up at 8 weeks and 12 months and abstraction of GP case notes.
Setting: 31 general practices in Trent region.
Participants: Patients aged 18-70 who met research diagnostic criteria for major depression; 103 patients were randomised and 220 patients were recruited to the preference arms.
Main outcome measures: Difference in mean Beck depression inventory score; time to remission; global outcome assessed by a psychiatrist using all data sources; and research diagnostic criteria.
Results: At 12 months there was no difference between the mean Beck scores in the randomised arms. Combining the randomised and patient preference groups, the difference in Beck scores was 0.4 (95% confidence interval -2.7 to 3.5). Patients choosing counselling did better than those randomised to it (mean difference in Beck score 4.6, 0.0 to 9.2). There was no difference in the psychiatrist's overall assessment of outcome between any of the groups. 221/265 (83%) of participants with a known outcome had a remission. Median time to remission was shorter in the group randomised to antidepressants than the other three groups (2 months v 3 months). 33/221 (15%) patients had a relapse.
Conclusions: Generic counselling seems to be as effective as antidepressant treatment for mild to moderate depressive illness, although patients receiving antidepressants may recover more quickly. General practitioners should allow patients to have their preferred treatment.


What is already known on this topic
Antidepressants and specific psychological interventions are effective in major depression.

Generic counselling has not previously been compared with antidepressants in primary care

What this study adds
12 months after starting treatment, generic counselling is as effective as antidepressants

Patients treated with antidepressants may recover more quickly

Given a choice, more patients opt for counselling

Patients who choose counselling may benefit more than those with no strong preference



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Rapid Responses:

Read all Rapid Responses

Improving preference measurement in primary care studies.
Andrew Martyn Thornett
bmj.com, 31 Mar 2001 [Full text]
Author’s conclusions were not justified by findings
Wai-Ching Leung
bmj.com, 1 Apr 2001 [Full text]
Doubtful 12 month intervention effects
Christopher Dowrick
bmj.com, 2 Apr 2001 [Full text]
Depression requires a multidimensional approach to managment
Steve Williams
bmj.com, 3 Apr 2001 [Full text]
Two distinct anti-depression treatments used together
Salvador Vale
bmj.com, 5 Apr 2001 [Full text]
further analysis
Arthur Rifkin
bmj.com, 13 Apr 2001 [Full text]
The type of treatment matters less than ensuring it is done properly and followed up
David Simpson
bmj.com, 30 Apr 2001 [Full text]
Does randomization introduce bias?
Toke S Barfod
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