Cognitive behavioral therapy and second-generation antidepressants are equally effective as treatments for major depression, according to new, evidence-based clinical guidelines published in the Annals of Internal Medicine.

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Major depressive disorder can be debilitating.

The guidelines urge physicians to discuss the effects of treatment, possible adverse effects, cost, accessibility and preferences with patients before choosing an approach.

Major depressive disorder (MDD) is a serious medical condition. In 2014, according to the National Institute of Mental Health (NIMH), around 6.7% of American adults, or 15.7 million of those aged 18 years and over, reported experiencing at least one major depressive episode in the previous year.

The effects of MDD include a lack of energy and loss of interest in things previously enjoyed, but symptoms can lead to disability and absenteeism from work or study, physical disease and even early death.

Treatments for MDD include cognitive behavioral therapy (CBT) and second-generation antidepressants (SGAs), but primary care physicians, usually the first port of call for patients with depression, often start by prescribing SGAs.

Fast facts about depression
  • MDD accounts for 3.7% of all US disability-adjusted life years (DALYs)
  • It accounts for 8.3% of years lived with disability in the US (YLDs)
  • In 2014, depression was most common in the 18-25 year age group, at 9.3%.

Learn more about depression

SGAs include including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitor (SNRIs), bupropion, mirtazapine, nefazodone and trazodone.

Adverse effects include constipation, diarrhea, nausea, headache, dizziness, sexual dysfunction, difficulty sleeping and drowsiness.

CBT combines cognitive and behavioral therapy. It focuses on changing a person’s thoughts and beliefs and their impact on mood and actions.

This can reduce unhealthy behavior patterns and help the individual to become healthier and more adaptive.

In minor and moderate depression, CBT can help to restructure negative thought patterns, to recognize the source of depression and to change the actions that exacerbate it.

Other non-drug treatments include complementary and alternative medicines or exercise therapies and combination therapies.

In the new guideline, the American College of Physicians (ACP) summarize and grade evidence comparing the effectiveness and safety of non-drug treatments and SGAs, alone or in combination, for MDD in adults.

The team evaluated response to treatment, remission, functional capacity, quality of life, reduction of suicide or suicidal ideation, hospitalizations and harms.

Moderate-quality evidence reflected similar levels of both effectiveness and discontinuation rates for CBT and SGAs. Low-quality evidence revealed little difference between SGAs and non-drug treatments in terms of effectiveness and adverse effects as a first-line treatment.

If taking SGAs does not improve a patient’s condition, low-quality evidence indicates that switching to another drug, adding another drug or adding or switching to non-drug therapy all have a similar effect as second-line treatment.

Low-quality evidence shows that St. John’s wort – an herbal medicine – may be as effective as SGAs; moderate-quality evidence suggests that St. John’s wort is better tolerated than SGAs.

However, St. John’s wort is not currently regulated by the Food and Drug Administration (FDA) in the US, so there are no standards regulating the contents and potency of the medication.

Quality-controlled St. John’s wort may, therefore, be hard to find. It may also be difficult to obtain preparations with similar effectiveness as those included in the studies.

Evidence shows that St. John’s wort can cause mild gastrointestinal symptoms, skin reactions, fatigue, sedation, restlessness, dizziness, headache and dry mouth. It can also interact with other drugs to cause adverse effects.

ACP President Dr. Wayne J. Riley says:

“CBT is a reasonable approach for initial treatment and should be strongly considered as an alternative treatment to SGAs where available, and after discussing treatment effects, adverse effect profiles, costs, accessibility and preferences with patients.”

Medical News Today recently reported on research suggesting that depression passes from mothers to daughters.