Major Depressive Disorder -Treatment
Psychotherapy or Pharmacotherapy?
In 1989, the National Institute of Mental Health (NIMH) completed the
most careful study ever done comparing the success rates of
psychotherapy vs. antidepressant drug therapy in the treatment of major
depression. Patients with major depression were assigned at random for
16 weeks to one of four treatments: an antidepressant drug
(imipramine), a placebo pill (monitored by brief, supportive, weekly
visits to a physician), interpersonal therapy, or cognitive behavioral
therapy. The interpersonal therapy focused on the immediate social
context of the depression and the depressed person's relations with
other people. The cognitive therapy focused on correcting the patient's
negative thinking, irrational guilt and pessimism.Most patients in all
four groups improved during treatment. The major findings were
surprising:
For the Less Severely Depressed Patients: (about 60% of the total) all
four treatments were equally effective. Placebo therapy (weekly visits
to a supportive physician to receive an inactive pill) was just as
effective as weekly visits to a psychologist or psychiatrist for
psychotherapy. Placebo therapy was just as effective as antidepressant
drug therapy.
For the Severely Depressed Patients: (about 40% of the total) the
antidepressant drug therapy was highly effective; for example, 76%
improved on imipramine and only 18% on the placebo. Interpersonal
therapy was moderately effective, but not as effective as
antidepressant drug therapy.For example, long-term interpersonal
therapy (once a month) was directly compared with imipramine for
ability to prevent recurrence of major depression among severely
depressed patients who recovered. The average time until a recurrence
was two-and-a-half years for patients taking the antidepressant drug, a
year-and-a-half for patients in psychotherapy, and ten months for those
who had neither. The interpersonal therapy provided no further help for
patients who were already taking the antidepressant drug.
Cognitive therapy, for these severely depressed patients, was
ineffective (being no better than placebo). The National Institute of
Mental Health study issued a warning. It concluded that only 16 weeks
of psychotherapy or antidepressant drug therapy for major depression
was insufficient since it resulted in very high relapse rates.
What are the important implications of this National Institute of
Mental Health study?
For Non-severe Major Depression: time-consuming or expensive
psychotherapy or antidepressant drug therapy is not needed.Non-severe
depression usually spontaneously recovers. According to one recent
study, the average episode of major depression lasts 4 months. In
another recent study, 40% of depressed patients recovered within three
months, 60% within six months, and 80% within a year. If the average
episode of major depression lasts 4 months, then for these mild cases,
all that is required is seeing a therapist frequently for brief,
supportive visits until the depression spontaneously recovers. For
Severe Major Depression: once there is major impairment in social or
vocational functioning, antidepressant drug therapy must be given.For
severe depression, antidepressant drug therapy is highly effective (for
example, in the NIMH study, 76% improved on imipramine and only 18% on
the placebo).
For severe depression, antidepressant drug therapy must be given for at
least 6-12 months, or even longer (since the NIMH study showed that
only 4 months of antidepressant drug therapy for major depression
resulted in very high relapse rates).
It would be medical malpractice to give a severely depressed patient
antidepressant drug therapy without some form of frequent, supportive
counselling.