Clinical management is important in treatment of depression

EDITOR—The striking finding of Malt et al's study in patients with depression is not the superiority of combined pharmacotherapy and psychotherapy but the 47% complete response rate to placebo and psychological support, which was present from about 12 weeks onwards.1 Unfortunately, little information is given about the quantity and quality of the psychological support provided, although reference is made to the clinical management protocol used in the National Institute of Mental Health's treatment of depression study, in which patients were seen regularly for 20-30 minute sessions of supportive therapy.2 3 In that study, at 16 weeks 42% of patients in the imipramine-clinical management group had recovered compared with 21% in the placebo-clinical management group.3

The difference between the studies is unlikely to be due to severity of illness as in both studies the initial rating indicated illnesses of moderate severity (Malt et al's study, mean initial Montgomery Åsberg depression rating scale=26.7; National Institute of Mental Health study, mean initial Hamilton rating scale for depression=19.5) However, the recovery criteria in Malt et al's study were less stringent—namely, a 50% reduction in the score on the Montgomery Åsberg depression rating scale and improvement to at least only mild illness remaining To compare the results usefully with those of other studies, data needed to be presented on the proportion of patients achieving …