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Chronic Depression
Medication (Nefazodone) or Psychotherapy (CBASP) Is Effective When the Other Is Not
Alan F. Schatzberg, MD;
A. John Rush, MD;
Bruce A. Arnow, PhD;
Phillip L. C. Banks, MS;
Janice A. Blalock, PhD;
Frances E. Borian, RN;
Robert Howland, MD;
Daniel N. Klein, PhD;
James H. Kocsis, MD;
Susan G. Kornstein, MD;
Rachel Manber, PhD;
John C. Markowitz, MD;
Ivan Miller, PhD;
Philip T. Ninan, MD;
Barbara O. Rothbaum, PhD;
Michael E. Thase, MD;
Madhukar H. Trivedi, MD;
Martin B. Keller, MD
Arch Gen Psychiatry. 2005;62:513-520.
Context Although various strategies are available to manage nonresponders to an initial treatment for depression, no controlled trials address the utility of switching from an antidepressant medication to psychotherapy or vice versa.
Objective To compare the responses of chronically depressed nonresponders to 12 weeks of treatment with either nefazodone or cognitive behavioral analysis system of psychotherapy (CBASP) who were crossed over to the alternate treatment (nefazodone, n = 79; CBASP, n = 61).
Design Crossover trial.
Setting Twelve academic outpatient psychiatric centers.
Patients There were 140 outpatients with chronic major depressive disorder; 92 (65.7%) were female, 126 (90.0%) were white, and the mean age was 43.1 years. Thirty participants dropped out of the study prematurely, 22 in the nefazodone group and 8 in the CBASP group.
Interventions Treatment lasted 12 weeks. The dosage of nefazodone was 100 to 600 mg/d; CBASP was provided twice weekly during weeks 1 through 4 and weekly thereafter.
Main Outcome Measures The 24-item Hamilton Rating Scale for Depression, administered by raters blinded to treatment, the Clinician Global Impressions–Severity scale, and the 30-item Inventory for Depressive Symptomatology–Self-Report.
Results Analysis of the intent-to-treat sample revealed that both the switch from nefazodone to CBASP and the switch from from CBASP to nefazodone resulted in clinically and statistically significant improvements in symptoms. Neither the rates of response nor the rates of remission were significantly different when the groups of completers were compared. However, the switch to CBASP following nefazodone therapy was associated with significantly less attrition due to adverse events, which may explain the higher intent-to-treat response rate among those crossed over to CBASP (57% vs 42%).
Conclusions Among chronically depressed individuals, CBASP appears to be efficacious for nonresponders to nefazodone, and nefazodone appears to be effective for CBASP nonresponders. A switch from an antidepressant medication to psychotherapy or vice versa appears to be useful for nonresponders to the initial treatment.
Author Affiliations: Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, Calif (Drs Schatzberg, Arnow, and Manber); Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas (Drs Rush and Trivedi); i3STATPROBE Inc, Dublin, Ohio (Mr Banks); Behavioral Science Department, University of Texas MD Anderson Cancer Center, Houston (Dr Blalock); Bristol-Myers Squibb Co, Plainsboro, NJ (Ms Borian); Department of Psychiatry, University of Pittsburgh School of Medicine (Drs Howland and Thase), Pittsburgh, Pa; Department of Psychology, State University of New York at Stony Brook (Dr Klein); Department of Psychiatry, Cornell University Medical College, New York, NY (Drs Kocsis and Markowitz); Department of Psychiatry, Virginia Commonwealth University, Richmond (Dr Kornstein); Department of Psychiatry and Human Behavior, Brown Medical School, Providence, RI (Drs Miller and Keller); and Department of Psychiatry, Emory University School of Medicine, Atlanta, Ga (Drs Ninan and Rothbaum).
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