Chronic depression: medication (nefazodone) or psychotherapy (CBASP) is effective when the other is not.
BACKGROUND
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).


METHODS
Crossover trial.


METHODS
Twelve academic outpatient psychiatric centers.


METHODS
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.


METHODS
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.


METHODS
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.
Schatzberg
Alan F
AF
Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94305-5717, USA. afschatz@stanford.edu
Rush
A John
AJ
Arnow
Bruce A
BA
Banks
Phillip L C
PL
Blalock
Janice A
JA
Borian
Frances E
FE
Howland
Robert
R
Klein
Daniel N
DN
Kocsis
James H
JH
Kornstein
Susan G
SG
Manber
Rachel
R
Markowitz
John C
JC
Miller
Ivan
I
Ninan
Philip T
PT
Rothbaum
Barbara O
BO
Thase
Michael E
ME
Trivedi
Madhukar H
MH
Keller
Martin B
MB
D000328:Adult; D018687:Antidepressive Agents, Second-Generation / Q000627:therapeutic use*; D002908:Chronic Disease; D015928:Cognitive Behavioral Therapy; D018592:Cross-Over Studies; D003865:Major Depressive Disorder / Q000175:diagnosis / Q000188:drug therapy* / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D010879:Piperazines; D011569:Psychiatric Status Rating Scales; D012044:Regression Analysis; D016019:Survival Analysis; D016896:Treatment Outcome; D014230:Triazoles / Q000627:therapeutic use*
D018687:Antidepressive Agents, Second-Generation; D010879:Piperazines; D014230:Triazoles; C051752:nefazodone