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Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care

BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7226.26 (Published 01 January 2000) Cite this as: BMJ 2000;320:26

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Maybe Try Therapy First

Mynors-Wallace et. al.may not have used the most sophisticated
research design. There is no evidence that either patients or raters were
blind to the treatment conditoin and there was not any form of
attention/placebo control. Nonetheless, the lack of a clear showing of
superiority for the medication only or medication and problem solving
treatment combination should cause primary care physicians to think about
referring to a psychotherapist or learning this problem solving approach
or having a nurse trained in this approach to attempt treatment for non-
suicidal patients with depression before prescribing antidepressants.

Antonuccio, DeNelsky, Danton, Greenberg and Gordon (1999), question
the safety of antidepressant medications and point to the side effects
resulting in many patients quitting trials due to the side effects.
Antidepressant medications are the most common agent used in suicide by
poisoning (Kapur, et al., 1992) and have been involved in as many as half
of serious adult overdoses (Kathol, et al., 1982). Although the number of
suicides is so small that the contribution of medication to suicide cannot
be proven, there is no evidence that the tests of combinations of
psychotropic drugs have been adequate or lengthy enough to assure safety

When a study truly blinds the patient and raters by testing two
different classes of medication and having placebo controls, the effects
are much smaller than when only one medication is tested and the chances
of guessing the substance taken is greater. Greenberg, Bornstein,
Greenberg, & Fisher (1992) found 22 such studies and performed a meta
analysis. They found that effect sizes were very modest, 0.25 - 0.31
standard deviation, when rated by a clinician. Neither class of drug,
tricyclic nor Serotonin Reuptake Inhibitor, fared better than a placebo
when rated by the patients. When psychotherapy and medication are
directly compared most studies either find that psychotherapy is either
comparable (Hollon, et al., 1991, Robinson, et al., 1990) or superior to
medications, especially in the long run (e.g., Covi, 1974; Dobson, 1989;
and Stainbrueck, et al., 1983).

Psychotherapy has been shown to be effective in both controlled and
clinical settings.(examples include the work or Aron T. Beck and
associates including Hollon, Luborski, et.al.,Seligman,1995; Shapiro and
Shapiro,1982, and Smith and Glass, 1977) Medication seems to have been
shown to be effective, but most studies that found medication to be
effective had serious flaws in the blinding of patients and raters.
Studies that compared the efficacy of psychotherapy and antidepressant
medications either found them to be equally effective or found
psychotherapy to be more effective. Additional studies have shown no
added positive effect of medication over therapy alone. Finally, overdose
of psychotherapy may be financially burdensome but it is never lethal.

Antonuccio, DeNelsky, Danton, Greenberg & Gordon, (1999). Raising
Questions about antidepressants. Psycho-therapy and Psychosomatics,
68(3), 3-14.

Antonuccio,DO, Danton,WG, & DeNelsky,GY, (1995). Psychotherapy
versus medication for depression: Challenging the conventional wisdom.
Professional Psychology, 26(6), 574-585.

Beck,AT,Hollon,SD, Young,JE, Bedrosian,RC, &Budenz,D, (1985).
Treatment of depression with cognitive therapy and amitriptyline. Archives
of General Psychiatry, 42, 142-148.

Blackburn,IM, Bishop,S., Glen,AI, Whalley, LJ, &Christie,JE,
(1981). The efficacy of cognitive therapy in depression: A treatmetn trial
using cognitive thrapy and pharmacotherapy, each alone and in combination.
British Journal of Psychiatry, 139, 181-189.

Blackburn,IM, Eunson,KM, & Bishop,S., (1985). A two-year
naturalistic follow-up of depressed patients treated with cognitive
therapy, pharmacotherapy, and a combination of both. Journal of Affective
Disorders, 10, 67-75.

Covi,L, Lippman,RS, Derogatis,LR, Smith,JE,& Pattison,JH,
(1974). Drugs and group psychotherapy in neurotic depression. American
Journal of Psychiatry,

Covi,L, Lippman,RS, (1987). Cognitive-behavioral group psychotherapy
combined with imiprimine in major depression. Psychopharmacology Bulletin,
23, 173-176.

Dobson,KS, (1989). A meta-analysis of the efficacy of cognitive
therapy for depression. Journal of Consulting and Clinical Psychology, 57,
414-419.

Evans,MD, Hollon,SD, DeRubeis,RJ, Piasecki,JM, Grove,WM, Garvey,MJ,
& Tuason,VB, (1992). Differential relapse following cognitive therapy
and pharmacotherapy for depression. Archives of General Psychiatry, 49,
802-808.

Greenberg,RP., Bornstein,RF, Zobrowski,MJ, Fisher,S, &
Greenberg,MD, (1994). A meta-analysis of fluoxetine outcome in the
treatment of depression. Journal of Nervous and Mental Disease, 182, 547-
551.

Greenberg,RP., Bornstein,RF, Greenberg,MD, & Fisher,S, (1992). A
meta-analysis of antidepressant outcome under “blinder” conditions.
Journal of Consulting and Clinical Psychology, 60, 664-669.

Hollon,SD, Shelton,RC, & LoosenPT, (1991). Cognitive therapy and
pharmacotherapy for depression. Journal of Consulting and Clinical
Psychology, 59,88-99.

Kapur,S, Mieczkowski,T, & Mann,JJ, (1992). Antidepressant
medication and the relative risk of suicide attempt and suicide. Journal
of the American Medical Association, 268, 3441-3445.

Kathol,RG & Henn,FA, (1982). Tricyclics: The most common agent
used in potentially lethal overdoses. Journal of Nervous and Mental
Disease, 171, 250-252.

Kovaks,M, Rush,AJ, Beck,AT,& Hollon,SD, (1981). Depressed
outpatients treated with cognitive therapy or pharmacotherpy: A one-year
follow-up. Archives of General Psychiatry, 38(1), 33-39.

Lipsey,M, & Wilson,D, (1993). The efficacy of psychological,
educational, and behavioral treatment: Confirmation from meta-analysis.
American Psychologist, 48, 1181-1209.

Luborsky, L, Crits-Christoph, P, McLellan, T, Woody, G, Piper,W,
Liberman, B, Imber, S, & Pilikonis, P, (1986). Do Therapists vary
much in their success? Findings from four outcome studies. American
Journal of Orthopsychiatry, 56 (4), 501-512.

Luborsky,L, Singer,B, & Luborsky,L, (1975). Comparative studies
of psychotherapies. Archives of General Psychiatry, 32, 995-1008.

Robinson,LA, Berman,JS, & NeimeyerRA, (1990). Psychotherapy for
the treatment of depression: A comprehensive review of controlled outcome
research. Psychological Bulletin, 108, 30-49.

Seligman, MEP, (1995). The effectiveness of psychotherapy: The
Consumer reports study. American Psychologist, 50, 965-974.

Shapiro, DA & Shapiro, D (1982). Meta-analysis of comparative
outcome studies: A replication and refinement. Psychological Bulletin,
92(3), 581-604.

Smith, ML & Glass, GV, (1977)Meta analysis of psychotherapy
outcome studies . American Psychologist ,32, 752-760.

Steinbrueck, SM, Maxwell., SE, & Howard, GS, (1983). A meta-
analysis of psychotherapy and drug therapy in the treatment of unipolar
depression with adults. Journal of Consulting and Clinical Psychology, 51
(6), 856-863.

Competing interests: No competing interests

04 January 2000
Steven Sproger
Mental Health Consultant
California Department of Health Services