Format for Mini-CAT
Clinical Question: Please state this as briefly as possible based on the scenario provided
A 24F with a PMH of Major Depressive Disorder is prescribed SSRIs by her psychiatrist but she is worried about negative side effects. She wants to know if there are any non-pharmacologic treatments available that can be as effective as medication.
PICO Question:
Identify the PICO elements (Recalling that some questions do not have all the elements)
Can Cognitive Behavioral Therapy be as effective as pharmacologic therapy in the treatment of Major Depressive Disorder?
P- Patients with MDD
I – Cognitive Behavioral Therapy
C- CBT vs. Pharmacotherapy
O – Improvement in quality of life, relief from depressive symptoms
Search Strategy:
Outline the terms used, databases or other tools used, how many articles returned, and how you selected the final articles to base your CAT on
Search terms: MDD, Major depressive disorder, cognitive behavioral therapy, CBT, depression, effectiveness, improvement
Databases: Pubmed, Cochrane Library
After filtering for articles in the last 5 years and from the NIH, I narrowed down my articles to about 200, and then searched for meta analyses that I thought would have the most convincing evidence.
Articles Chosen for Inclusion (please copy and paste the abstract with link):
Summary of the Evidence:
| Author (Date) | Level of Evidence | Sample/Setting
(# of subjects/ studies, cohort definition etc. ) |
Outcome(s) studied | Key Findings | Limitations and Biases | ||
Cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are the two first-line treatments for depression, but little is known about their effects on quality of life. |
Meta- analysis | 24 studies representing 1,969 patients who received CBT, compared to 13 studies of 4,286 patients receiving pharmacotherapy. | Improvements in QOL | Patients undergoing CBT experienced significant QOL improvements, but not those on pharmacotherapy | Some patients receiving CBT may have also been stabilized on pharmacotherapy, later publication year showed smaller increase in QOL | ||
| Qaseem A, Barry MJ, Kansagara D, for the Clinical Guidelines Committee of the American College of Physicians. Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients With Major Depressive Disorder: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016;164:350–359. [Epub ahead of print 9 February 2016]. doi: https://doi.org/10.7326/M15-2570
Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the comparative effectiveness of treatment with second-generation antidepressants versus nonpharmacologic treatments for major depressive disorder in adults.
|
Meta-analysis | 8 Trials comparing second generation antidepressants vs CBT | Response to treatment | 5 moderate quality evidence trials showed no difference in treatment between SGA and CBT after 8-52 weeks. | Insufficient evidence to compare 3rd wave CBT harms and benefits to SGA. | ||
| Weersing, V Robin et al. “Evidence Base Update of Psychosocial Treatments for Child and Adolescent Depression.” Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53 vol. 46,1 (2017): 11-43. doi:10.1080/15374416.2016.1220310
Depression in youth is prevalent and disabling and tends to presage a chronic and recurrent course of illness and impairment in adulthood. Clinical trial research in youth depression has a 30 year history, and evidence-based treatment reviews appeared in 1998 and 2008. The current review of 42 randomized controlled trials (RCTs) updates these reviews to include RCTs published between 2008 and 2014 (N = 14) and re-evaluates previously reviewed literature. Given the growing maturity of the field, this review utilized a stringent set of methodological criteria for trial inclusion, most notable for excluding trials based in sub-clinical samples of youth that had been included in previous reviews (N = 12) and including well-designed RCTs with null and negative findings (N = 8). Findings from the current review suggest that evidence for child treatments is notably weaker than for adolescent interventions, with no child treatments achieving well-established status and the evidentiary basis of treatments downgraded from previous reports. Cognitive behavioral therapy (CBT) for clinically depressed children appears to be possibly efficacious, with mixed findings across trials. For depressed adolescents, both CBT and Interpersonal Psychotherapy (IPT) are well-established interventions, with evidence of efficacy in multiple trials by independent investigative teams. This positive conclusion is tempered by the small size of the IPT literature (N = 6) and concern that CBT effects may be attenuated in clinically complicated samples and when compared against active control conditions. In conclusion, data on predictors, moderators, and mediators are examined and priorities for future research discussed.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5296370/
|
Meta Analysis | 27 Trials | Improvement of depressive symptoms | Individual CBT in adolescents seems to reliably improve symptoms of MDD | Some studies of CBT evaluated failed to show CBT performing better than control. | ||
This study aims to summarise the evidence on more than 140 pharmacological and non-pharmacological treatment options for major depressive disorder (MDD) and to evaluate the confidence that patients and clinicians can have in the underlying science about their effects.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5623437/
|
Meta- analysis | 19 systematic reviews | Treatment of MDD | CBT is the only behavioral therapy reliably shown to produce responses in treatment similar to second generation antidepressants. | Did not take simultaneous therapies into consideration, though this is a common treatment practice. | ||
| David, Daniel et al. “Why Cognitive Behavioral Therapy Is the Current Gold Standard of Psychotherapy.” Frontiers in psychiatry vol. 9 4. 29 Jan. 2018, doi:10.3389/fpsyt.2018.00004
Taking into account the number of publications/studies, academic programs, and/or practicing professionals, cognitive behavioral therapy (CBT) is arguably the gold standard of the psychotherapy field. However, recently, some colleagues have argued for plurality in psychotherapy, questioning the status of CBT as the gold standard in psychotherapy (1), because many studies are of low quality and/or the comparator conditions are weak (i.e., wait list rather than active comparators), thus challenging CBT’s prominent status among academic programs and practitioners.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5797481/
|
Literature review | 13 studies and reviews | Argues that CBT should be considered the gold standard psychological treatment, no other non-pharmacologic treatment modality has better results and also has less negative side effects than medication | Included studies that utilized CBT with anxiety as well as depression, admits many CBT studies have weak control comparisons | |||
Conclusion(s):
CBT appears to be just as effective in treating major depressive disorder in many cases and can be considered a first line treatment. Many medications for MDD cause negative side effects on libido, mental status, and sleep patterns, which can cause non-compliance or discontinuation. CBT has demonstrated effective treatment without the side effects of pharmacologic therapy.
Clinical Bottom Line:
Please include an assessment of the worth to practice
I believe that CBT has the potential to be the gold standard and front-line treatment for MDD, before resorting to antidepressant medication. The lack of side effects makes this an appealing option for people that are worried about them or those with medication-resistant MDD.
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