Both antidepressant medications and cognitive therapy have been shown to be effective for the treatment of depression; however, the question remains as to whether one treatment is preferred over the other. Subjects enrolled in The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study (men and women with major depression, ages 18-75) were initially treated with citalopram, an SSRI. Those who had unsatisfactory outcomes after initial treatment were eligible for a randomized second-step treatment trial in which they switched to a new treatment (either cognitive therapy or a different antidepressant) or augmented the citalopram regimen with either cognitive therapy or a different antidepressant.

The rates of remission of depressive symptoms following this second-step were not significantly different between those who were in medication-only treatment pathways and those who either switched to cognitive therapy or augmented with cognitive therapy. This suggests that cognitive therapy is as effective as medication in treating depression. Remission took an average of one month longer to achieve in those who augmented the citalopram with cognitive therapy instead of with an antidepressant. However, those who switched to an antidepressant experienced significantly more side effects than those who switched to cognitive therapy.

Although women who were pregnant or breastfeeding were excluded from the study, these results should be taken into consideration when developing treatment algorithms for reproductive-aged women with depression. In some cases, taking a medication may make a patient more inclined to begin cognitive therapy, or vice versa. Smaller scale studies have demonstrated that cognitive therapy is as effective as medication for treating postpartum depression (Appleby et al 1997), and several other studies have indicated that interpersonal therapy is effective for treating both antenatal and postpartum depression (O’Hara et al 2000, Spinelli 1997, Stuart and O’Hara 1995). The efficacy of a treatment, the quickness with which one can achieve remission of symptoms, the reproductive safety of a given intervention, and the side effects of a treatment are all factors that must taken into consideration when caring women who are pregnant, planning a pregnancy, or postpartum.

Ruta Nonacs, MD PhD
Katherine Donovan, BA

Thase ME, Friedman ES et al. Cognitive therapy versus medication in augmentation and switch strategies as second-step treatments: A STAR*D report. American Journal of Psychiatry. 2007; 164(5): 739-52.

To read more on this topic:

Cognitive Therapy and Interpersonal Psychotherapy: 30 Years Later (Weissman MM)

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