Are Treatment Preferences Relevant in Response to Serotonergic Antidepressants and Cognitive-Behavioral Therapy in Depressed Primary Care Patients? Results from a Randomized Controlled Trial Including a Patients’ Choice Arm

Abstract

Background: Little is known about the influence of depressed patients’ preferences and expectations about treatments upon treatment outcome. We investigated whether better clinical outcome in depressed primary care patients is associated with receiving their preferred treatment. Methods: Within a randomized placebo-controlled single-centre 10-week trial with 5 arms (sertraline; placebo; cognitive-behavioral group therapy, CBT-G; moderated self-help group control; treatment with sertraline or CBT-G according to patients’ choice), outcomes for 145 primary care patients with mild-to-moderate depressive disorders according to DSM-IV criteria were investigated. Preference for medication versus psychotherapy was assessed at screening using a single item. Post-baseline difference scores for the Hamilton Depression Rating Scale (HAMD-17) were used to assess treatment outcome (mixed-model repeated-measures regression analysis). Results: Depressed patients receiving their preferred treatment (n = 63), whether sertraline or CBT-G, responded significantly better than those who did not receive their preferred therapy (n = 54; p = 0.001). The difference in outcome between both groups was 8.0 points on the HAMD-17 for psychotherapy and 2.9 points on the HAMD-17 for treatment with antidepressants. Results were not explained by differences in depression severity or dropout rates. Conclusions: Patients’ relative preference for medication versus psychotherapy should be considered when offering a treatment because receiving the preferred treatment conveys an additional and clinically relevant benefit (HAMD-17: +2.9 points for drugs; +8.0 points for CBT-G) in outcome.

Treatment preferences in patients with first episode depression

“…Shared decision making needs to be encouraged, due to its positive impact on adherence to treatment and clinical results (Kocsis et al, 2009;Clever et al, 2006;Loh et al, 2007;Lin et al, 2005;Mergl et al, 2011).…”

“…As for psychotherapy, according to Canadian recommendations a minimum of 12 visits are needed, but only 60% of patients having begun psychotherapy receive this much treatment (Duhoux et al, 2012) Under current guidelines, health professionals and, in particular, physicians need to take patient preferences into account in order to encourage adherence and effective treatment of depression (Trivedi et al, 2007;APA, 2000;NICE, 2009). Patients obtaining their preferred treatment (whether psychotherapy or pharmacotherapy) is associated with the best clinical results, particularly in terms of better remission rates but also in terms of a more significant reduction in depressive symptomatology (Clever et al, 2006;Gelhorn et al, 2011;Kocsis et al, 2009;Loh et al, 2007;Lin et al, 2005;Mergl et al, 2011). Persons suffering from depression often have very clear preferences (Churchill et al, 2000;Dwight-Johnson et al, 2000) and want to play an active role in treatment selection (Stacey et al, 2008;Arora and McHorney, 2000).…”

“…Persons suffering from depression often have very clear preferences (Churchill et al, 2000;Dwight-Johnson et al, 2000) and want to play an active role in treatment selection (Stacey et al, 2008;Arora and McHorney, 2000). While physicians generally prefer antidepressants, patients often prefer psychotherapy (Van Schaik et al, 2004;Löwe et al, 28;Khalsa et al, 2011;Churchill et al, 2000;Dwight-Johnson et al, 2000;Iacoviello et al, 2007;Mergl et al, 2011).…”

Outcomes of Acute Phase Cognitive Therapy in Outpatients with Anxious versus Nonanxious Depression

“…An additional important avenue of future research is testing whether anxious depression is a moderator of between-group differences in randomized controlled trials comparing CT to antidepressant medications or their combination. A recent report further suggests that it may be important to measure and include in the analyses patient preferences for treatment, because receiving the preferred treatment has been associated with improved outcomes both for CT and pharmacotherapy [29]. Results of such efforts can ultimately best guide recommendations for appropriate treatment modalities for anxious depressed patients.…”

The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults

“…Interventions have included antidepressant medication as compared with forms of psychotherapy (e.g., cognitivebehavioral therapy, cognitive behavioral analysis system of psychotherapy, supportive therapy) or combined treatment with antidepressant and psychotherapy. Findings of these studies are mixed, with some (Kocsis et al 2009;Lin et al 2005;Mergl et al 2011) but not all (Dunlop et al 2012;Kwan et al 2010;Leykin et al 2007;Steidtmann et al 2012) showing greater or more rapid symptom reduction among individuals who received their preferred treatment. Other secondary analyses showed better reported therapeutic alliance among individuals who received their preferred treatment in some studies (Iacoviello et al 2007;Kwan et al 2010).…”