Dysthymia: a randomized study of cognitive marital therapy and antidepressants

WITHDRAWN: Drugs versus placebo for dysthymia

This review has been withdrawn due to non‐compliance with Cochrane's Commercial Sponsorship Policy.

The editorial group responsible for this previously published document have withdrawn it from publication.

Pharmacotherapy of dysthymia: review and new findings

Open trials with tricyclics, classical monoamine oxidase inhibitors (MAOIs) or lithium in dysthymia yielded a response rate in 45% of subjects. A long-term treatment of dysthymia with 276 patients treated during 4 years with either moclobemide, tranylcypromine or a combination of amitryptiline plus chlordiazepoxide is described. After discontinuation there was a relapse rate of 89.1%. The controlled studies with tricyclics, MAOIs, reversible inhibitors of monoamine oxidase (RIMAs), specific serotonin reuptake inhibitor (SSRIs) or benzamides showed that drugs well-tolerated work better in dysthymia, due to the fact that the treatment must be long-term. Sertraline was studied vs placebo or imipramine in primary dysthymia. Moclobemide, imipramine and placebo were also studied in 315 patients. Mean doses were 650 mg/d of moclobemide and 203.2 mg/d of imipramine. Moclobemide and sertraline were both efficacious and well tolerated. In a long term treatment the clinician should assess the risk-benefit ratio. Dysthymic patients are very sensitive to unwanted effects and compliance is a serious issue.

Psychological treatment of depression in inpatients: a systematic review and meta-analysis

Research on psychological treatment of depression in inpatients is not conclusive, with some studies finding clear positive effects and other studies finding no significant benefit compared to usual care or structured pharmacotherapy. The results of a meta-analysis investigating how effective psychological treatment is for depressed inpatients are presented. A systematic search in bibliographical databases resulted in 12 studies with a total of 570 respondents. This set of studies had sufficient statistical power to detect small effect sizes. Psychological treatments had a small (g=0.29), but statistically significant additional effect on depression compared to usual care and structured pharmacological treatments only. This corresponded with a numbers-needed-to-be-treated of 6.17. Heterogeneity was zero in most analyses, and not significant in all analyses. There was no indication for significant publication bias. Effects were not associated with characteristics of the population, the interventions and the design of the studies. Although the number of studies was small, and the quality of many studies was not optimal, it seems safe to conclude that psychological treatments have a small but robust effect on depression in depressed inpatients. More high-quality research is needed to verify these results.

A comparative trial of psychotherapy and pharmacotherapy for "pure" dysthymic patients

BACKGROUND

Psychotherapy of "pure" dysthymic disorder remains understudied. This article reports outcomes of an acute randomized trial of 94 subjects treated for 16 weeks with either interpersonal psychotherapy (IPT), brief supportive psychotherapy (BSP), sertraline, or sertraline plus IPT.

METHODS

Recruited by clinical referral and advertising, subjects met DSM-IV criteria for early onset dysthymic disorder, with no episode of major depression in the prior six months. They were randomly assigned to one of four 16-week treatments, with options for crossover or continuation treatment. Results were analyzed from the intention-to-treat sample by ANCOVA, controlling for baseline depressive severity.

RESULTS

Subjects improved in all conditions over time, with the cells including sertraline pharmacotherapy showing superiority over psychotherapy alone for response and remission. Response rates were 58% for sertraline alone, 57% for combined treatment, 35% for IPT, and 31% for BSP.

LIMITATIONS

The study was underpowered and may have employed too "active" a control condition. Follow-up data were unobtainable.

CONCLUSIONS

In this acute trial for "pure" dysthymic disorder, sertraline with or without IPT showed advantages relative to IPT and BSP. Methodological difficulties may have limited differential outcome findings. This study bolsters a small but growing literature on the treatment of dysthymic disorder, suggesting that pharmacotherapy may acutely benefit patients more than psychotherapy.

Breaking the myths: new treatment approaches for chronic depression

BACKGROUND

Chronic depressive disorders are common, accounting for approximately one-third of all cases of depression and posing a major public health problem. In the past, chronic depression has been thought to be treatment-resistant, and evidence suggests that it is currently underdiagnosed, misdiagnosed, and suboptimally treated.

OBJECTIVES

To review the subtypes of chronic depression and the evidence-base concerning their optimal treatment and to discuss some key clinical issues and areas of future research.

METHODS

We identified key studies and randomized controlled trials (RCTs) by systematically searching electronic databases and hand searching specialist journals and bibliographies.

RESULTS

Chronic depressive disorders respond well to standard pharmacologic interventions in the acute and maintenance phases of treatment. Standard psychotherapies alone may not be efficacious for chronic depression (especially dysthymia). Recent evidence suggests that treatment combining psychotherapy and medications may be superior to either treatment alone.

CONCLUSIONS

Chronic depressive disorders are amenable to treatment, provided that intervention is both thorough and intensive. Although our knowledge about the optimal treatment of chronic depression has developed rapidly, changes in clinical practice have been slower to evolve. Further research is required to assess the effectiveness of multimodal interventions for chronic depression in more naturalistic settings.

Sertraline and/or interpersonal psychotherapy for patients with dysthymic disorder in primary care: 6-month comparison with longitudinal 2-year follow-up of effectiveness and costs

BACKGROUND

There is little information on the long-term effects and costs of a combination of Sertraline and interpersonal psychotherapy (IPT) for the treatment of dysthymia in primary care.

METHODS

In a single-blind, randomized clinical trial, 707 adults (18-74 years of age inclusive) with DSM-IV dysthymic disorder, with or without past and/or current major depression, as an acute or chronic episode, in a community-based primary care practice in Ontario, Canada, were randomized to treatment with either Sertraline alone (50-200 mg), or IPT alone (10 sessions), or Sertraline plus IPT combined. In the acute treatment phase (first 6 months) all groups received full active treatment. This was followed by an additional 18-month naturalistic follow-up phase. Subjects were assessed for effectiveness of treatment in reducing depressive symptoms using the Montgomery Asberg Depression Rating Scale (MADRS) at 6 months and twice again during the 18-month follow-up by blind independent observers. Treatment costs and subjects' use of other health and social services were also investigated.

RESULTS

At 6 months, 586 subjects completed the MADRS questionnaire. There was a significant difference (P=0.025) in mean MADRS scores: 14.3 (Group I); 14.9 (Group II); 16.8 (Group III), using analysis of covariance. Response (40% improvement) rates were 60.2% for Sertraline alone, 46.6% for IPT alone, and 57.5% for Sertraline augmented by IPT (P=0.02). At 2 years, 525 subjects were retained for follow-up. There was no statistically significant difference between Sertraline alone and Sertraline plus IPT in symptom reduction. However, both were more effective than IPT alone in reducing depressive symptoms (P=0.03). There was a statistically significant difference between groups in costs for use of health and social services. The IPT treatment groups had the lower costs for use of health and social services.

CONCLUSIONS

Sertraline or Sertraline plus IPT was more effective than IPT alone after 6 months. Over the long term (2 years), all three treatments provide reasonably effective treatment for reducing symptoms of dysthymia, but Sertraline or combining Sertraline with IPT is more effective than IPT alone. Of these two more effective treatments, subjects in the Sertraline plus IPT group had less health and social service costs by $480 per person over 2 years. These findings underscore the effects of combining pharmacotherapy and psychotherapy and the economic value of this more comprehensive treatment of dysthymia in primary care.

The London Depression Intervention Trial. Randomised controlled trial of antidepressants v. couple therapy in the treatment and maintenance of people with depression living with a partner: clinical outcome and costs

BACKGROUND

Relapse of depression is associated with a criticising attitude of the patient's partner.

AIMS

To compare the relative efficacy and cost of couple therapy and antidepressant drugs for the treatment and maintenance of people with depression living with a critical partner.

METHOD

A randomised controlled trial of antidepressant drugs v. couple therapy. The subjects were 77 people meeting criteria for depression living with a critical partner.

RESULTS

Drop-outs were 56.8% [corrected] from drug treatment and 15% from couple therapy. Subjects' depression improved in both groups, but couple therapy showed a significant advantage, according to the Beck Depression Inventory, both at the end of treatment and after a second year off treatment. Adding the costs of the interventions to the costs of services used showed there was no appreciable difference between the two treatments.

CONCLUSIONS

For this group couple therapy is much more acceptable than antidepressant drugs and is at least as efficacious, if not more so, both in the treatment and maintenance phases. It is no more expensive overall.

A comparison of drugs versus placebo for the treatment of dysthymia

OBJECTIVES

Dysthymia is a depressive disorder of chronic nature but of less severity than major depression, which depressive symptoms are more or less continuous for at least two years. The aim of this review was to conduct a systematic review of all RCTs comparing drugs and placebo for dysthymia.

SEARCH STRATEGY

Electronic searches of Cochrane Library, EMBASE, MEDLINE, PsycLIT, Biological Abstracts and LILACS; reference searching; personal communication; conference abstracts; unpublished trials from the pharmaceutical industry; book chapters on the treatment of depression.

SELECTION CRITERIA

The inclusion criteria for all randomised controlled trials were that they should focus on the use of drugs versus placebo for dysthymic patients. Exclusion criteria were: non randomised, mixed major depression/ dysthymia (trials not providing separate data) and depression secondary to other disorders (e.g. substance abuse).

DATA COLLECTION AND ANALYSIS

The reviewers extracted the data independently. In order to achieve an intention-to-treat analysis, when trials failed to report it was assumed that people who died or dropped out had no improvement. Authors of relevant trials were contacted for additional and missing data. Absence of treatment response as defined by authors was the main measure of outcome used. Relative Risks (RR) and 95% confidence intervals (CI) of dichotomous data were calculated with the Random Effects Model. Where possible, number needed to treat (NNT) and number needed to harm (NNH) were estimated, taking the reciprocal of the absolute risk reduction.

MAIN RESULTS

Currently the review includes 15 trials. Similar results were obtained in terms of efficacy for different groups of drugs, such as tricyclic (TCA), selective serotonin reuptake inhibitors (SSRI), monoamine oxidase inhibitors (MAOI) and other drugs (sulpiride, amineptine, and ritanserin). The pooled RR for absence of treatment response was 0. 68 (95% CI 0.59-0.78) for TCA and the NNT was 4.3 (95% CI 3.2-6.5). SSRIs showed similar RR for this outcome: 0.64 (95% CI 0.55-0.74), the NNT being 4.7 (95% CI 3.5-6.9). Concerning MAOIs, the RR was 0. 59 (95% CI 0.48-0.71) and the NNT was 2.9 (95% CI 2.2-4.3). Other drugs (amisulpride, amineptine and ritanserin) showed similar results in terms of absence of treatment response. Using more stringent criteria for improvement - full remission - the results were unchanged. Patients treated on TCA were more likely to report adverse events, compared with placebo.

REVIEWER'S CONCLUSIONS

Drugs are effective in the treatment of dysthymia with no differences between and within class of drugs. Tricyclic antidepressants are more likely to cause adverse events and dropouts. As dysthymia is a chronic condition, there remains little information on quality of life and medium or long-term outcome.

Combined medication and psychotherapy in the treatment of chronic mood disorders

This article discusses the use of combined treatments for patients with chronic mood disorders. Although very little research concerning the efficacy of combined treatments for patients with chronic depression exists, clinical experience and limited available research suggest that combined treatment may be the most effective treatment option available for this population. The use of combination treatment involving pharmacotherapy, individual psychotherapy, and marital/family therapy is recommended to address the complex biopsychosocial issues involved in chronic mood disorders. Other theoretical and pragmatic issues concerning the delivery of combined treatment also are discussed.

Psychotherapy for dysthymic disorder

The psychotherapy of dysthymic disorder has received too little serious attention and funding. Impressive advances in the pharmacotherapy of dysthymic disorder should not obscure the need for psychosocial treatment for the high proportion of patients who do not respond to medication. Despite the dearth of psychotherapy outcome studies in this area, such data that do exist suggest that relatively brief, focal, antidepressant psychotherapies may successfully treat many patients with lifelong mood disorders. Maintenance therapy probably is indicated to ensure the persistence of treatment gains.