Talk therapy may help tough-to-treat depression

NEW YORK (Reuters Health) -- People with long-lasting depression may benefit from talk therapy when other treatment methods such as antidepressant drugs alone aren’t working, suggests a new study. But the topic needs more research, the authors say - and they also point out that talk therapy isn’t accessible or affordable for everyone.

About 15 million adults in America suffer from major depressive disorder - serious cases of depression that last more than two weeks - in any given year, according to the National Institute of Mental Health. Most people who are diagnosed with major depressive disorder get prescribed an antidepressant rather than going straight into talk therapy, explained Dr. Ranak Trivedi, the lead author on the current study from the University of Washington School of Public Health.

But up to half of those people might not feel any better after they start taking the medication, she said.

Guidelines point doctors to a few different options for treating patients who don’t respond to their first antidepressant drug. The doctor can add a new antidepressant to the first one, or switch drugs completely. Sometimes it takes several attempts to find the drug or drugs that will help the patient feel better. They can also refer the patient to talk therapy, either in addition to medication or instead of medication.

However, “though the guidelines seem to suggest there are four ways to approach treating people who don’t respond to (the first) treatment, we tend to gravitate toward giving medication,” Trivedi told Reuters Health.

To see if patients could be getting more out of talk therapy instead of switching between different antidepressants, Trivedi and her colleagues reviewed a series of seven studies involving nearly 600 adults with major depressive disorder who hadn’t been helped by medication.

In each of the studies, researchers either took patients off antidepressant medications and substituted talk therapy, or they added therapy on top of patients’ usual medication routine. Then they compared those patients to others who stayed on their antidepressant drug, switched to a new drug, or had another drug added to their original medication - but didn’t have any talk therapy.

Each of the studies was a “randomized” trial, meaning participants and doctors didn’t get to choose which treatment the patients got; instead, the assignments were made by chance. This type of study is the most reliable.

Taken together, the results published in the Journal of General Internal Medicine were generally favorable. Some of the studies suggested that patients improved more when they were in therapy and on medication than when they were only taking medication. Others showed that adding or switching to talk therapy was beneficial, but not any more so than changing a patient’s prescription or having the patient take additional drugs.

Researchers say the results show that talk therapy may be promising for people who don’t get better on medication - but they also reflect the fact that many more studies are needed.

As it becomes clearer that the first try at an antidepressant doesn’t work for many people, “it’s apparent that greater attention needs to be paid to this whole other avenue of treatment for people who aren’t responding to first and second and third choice medications,” Dr. Michael Thase told Reuters Health. Thase, a psychiatrist at the University of Pennsylvania School of Medicine, has participated in some of the research that suggests that talk therapy can be beneficial. (He wasn’t involved in Trivedi’s study, however.)

For some patients, however, getting access to talk therapy is more difficult and costly than taking medications, which have gotten cheaper as generic versions became available. As of August 2010, according to data from Wolters Kluwer Pharma Solutions reported by Consumer Reports, average monthly costs for antidepressants were as low, for example, as $19 for fluoxetine (the generic form of Prozac), $26 for sertraline (Zoloft), and $35 for citalopram (Celexa).

Talk therapy costs more than medication, at least in the short term. And insurance companies often put limits on reimbursements (although new rules issued by the Obama administration are intended to improve coverage of mental health care for people whose insurance comes through their employers).

But Trivedi said that in the long run, talk therapy may well be worth it. “People who take antidepressants often end up taking them for life,” she said. With talk therapy, patients often go for a few months, or sometimes a few years, and then stop when their symptoms have gone away.

The bottom line is, treatment choices should come down to what the patient prefers, Thase said. In the early stages of chronic depression, “you should pick the (treatment) that you want, or the combination, and go with that. Then consider the alternative if three months into it you’re no better.”

Trivedi agreed that people with depression should try to be attuned to the kind of help they want and need, while not losing hope of getting better. For those with chronic depression, she said, “keep at it. If you don’t respond to the first treatment, you’re not alone.”

SOURCE: Journal of General Internal Medicine, online December 24, 2010.