Adding CBT to meds is effective, but slow.
The results of the cognitive therapy component of the NIMH-funded STAR-D trial were finally released. Recall that in STAR-D, about 4,000 depressed patients were initially enrolled and were all given Celexa (citalopram) at an average dose of about 40 mg/day (see TCPR January 2007 for a rundown of STAR-D findings). Of the initial 4,000, about 1,500 patients either did not respond or did not tolerate Celexa, and were assigned to a variety of medication or psychotherapy trials. Patients randomized to augmentation of their Celexa with CBT had similar remission rates to those who received either Wellbutrin or BuSpar augmentation. However, CBT augmentation was slower, taking about 55 days to work, vs. medication’s 40 days. On the other hand, patients who were randomized to switching from Celexa to either CBT or another antidepressant responded identically to both strategies, with no time course difference (Thase ME, et al., Am J Psychiatry 2007;164:739-752).
TCPR’s Take: For patients who do not respond to an adequate SSRI trial, augmenting with either Wellbutrin or BuSpar appears to work faster than adding CBT, although meds can cause more side effects. However, since STAR-D’s design was not placebo-controlled, blinded, nor fully randomized, it is difficult to have a great deal of confidence in any of its findings, including this one.
Antidepressant suicide warning for young adults.
The FDA has announced that it will require antidepressant drug makers to add a black box warning for patients aged 18-24 warning of a risk of suicidal events. Recall that in 2004, the FDA ordered a similar black box warning for children and adolescents. That was based on a review of all placebo-controlled double blind trials of antidepressants in children, which revealed that antidepressants led to roughly twice the rate of suicidal events than placebo. Since then, the FDA requested similar data on all adults in antidepressant trials. After two years of number-crunching, they discovered that antidepressants do not cause suicidality in adults; however, when you separate out the 18-24 age group, antidepressants conferred a 1.55 times greater risk of suidical events. (For an excellent commentary, see Friedman RA and Leon AC, NEJM 2007: May 7, published online.)
TCPR’s Take: We supported the earlier warning, largely because antidepressants may be ineffective for pediatric depression, and double the risk of a catastrophic event is intolerable when the potential benefits are so slim. The FDA has gone overboard this time, however. Antidepressants are clearly effective in young adults, and certainly act to prevent more suicidal ideation than they produce. This black box will probably decrease antidepressant prescribing for these patients, and that, in turn, may increase the suicide rate.
Mindfulness meditation helps with depression of fibromyalgia.
Fibromyalgia is usually considered a rheumatologic condition characterized by at least 3 months of widespread pain and the presence of tender points. About two thirds of fibromyalgia patients also suffer from depression, and many such patients eventually find their way to our offices. Effective treatments for fibromyalgia include antidepressants, excercise programs, and cognitive behavioral therapy. A new study randomized 91 women with fibromyalgia to either eight weekly 2.5 hour mindfulness meditation sessions or a waiting list control. At 2 month follow-up, depressive symptoms improved more in the meditation group than the control group (Sephton SE, et al., Arthritis and Rheumatism 2007;57:77-85).
TCPR’s Take: It would have been better to see mindfulness meditation compared with antidepressants or another active treatment, but this study is encouraging. Mindfulness meditation is now something else that we can recommend to these patients, many of whom have been suffering for years and have found other approaches unhelpful.
Monitoring alcohol use may be enough for some.
Project Match was a large, government-funded research project conducted in the 1990s that showed equivalent benefit of AA, cognitive behavioral therapy, and motivational enhancement therapy in alcoholism. Researchers recently reported on an effort to test brief versions of the Project Match therapies for alcohol abusing patients. Ninety eight non-dependent but heavy drinkers were randomly assigned to brief coping skills, brief motivational enhancement, or waiting list conditions. All groups were given handheld computers to monitor their daily drinking before, during, and after the interventions. At followup, there were no differences between the two intervention groups, and while the waiting list group drank more throughout, they did decrease their drinking significantly (Ball SA, et al., Addict Behav 2007;32:1105-1118).
TCPR’s Take: Simply asking alcohol abusing patients to keep a daily log of how often and how much they drink is likely to help them moderate their drinking, even in the absence of specific treatment.