Am Fam Physician. 2006;74(9):1580-1581
Clinical Question
Are psychosocial interventions by primary care physicians as effective as antidepressants for symptom relief in patients with major depression?
Evidence-Based Answer
Few high-quality studies have been conducted examining the effectiveness of psychosocial interventions performed by primary care physicians for patients with major depression. Two randomized controlled clinical trials (RCTs) found that a psychosocial intervention, specifically problem-solving therapy, is as effective as pharmacotherapy for symptoms of major depression.1,2 (Strength of recommendation: B) However, these results should be interpreted with some degree of caution because of the limited number of studies and their small sample size.
Evidence Summary
One RCT compared a psychosocial intervention (problem-solving therapy) delivered by a primary care physician with the antidepressants fluvoxamine (Luvox) and paroxetine (Paxil) in patients with major depression.1 It found no differences between the two groups in scores on depression scales at six-, 12-, or 52-week follow-up (Table 1).1 However, the results should be interpreted with caution because the treatments were provided by three “research general practitioners” and were supervised by the researcher conducting the study. Furthermore, the problem-solving group (39 participants) and the medication group (36 participants) contained fewer participants than are needed to detect a potentially clinically-important difference.
In a second RCT by the same researchers, problem-solving assistance, delivered by two general practitioners and a psychiatrist, was compared with the antidepressant amitriptyline and placebo.2 The study included 91 patients with major depression and did not find any significant differences in depression scores at six- or 12-week follow-up between the two groups (using the Beck Depression Inventory, the Hamilton Rating Scale for Depression, and the Social Adjustment Scale).
For both studies, the specific psychosocial intervention of problem solving consisted of six 30- to 60-minute sessions over a 12-week period; session time was spent clarifying and defining problems, setting realistic goals, developing and deciding upon solutions, implementing a chosen solution, and performing evaluation.1,2 A systematic review of the literature, which included the previously discussed RCTs, combined data from the two studies to improve the sample size and statistical power.3 The authors concluded that there was good evidence that problem solving delivered by general practitioners was as effective as antidepressants for major depression.
The results of these studies may not be generalizable to all primary care physicians given that formal training in problem-solving therapy is not a standard part of all residencies. However, the Accreditation Council for Graduate Medical Education does state in the Program Requirements for Graduate Medical Education in Family Medicine that there must be instruction in “counseling skills.”4
| Mean Scores* | ||
|---|---|---|
| Dependent Measures | Problem solving (39 participants) | Medication alone (36 participants) |
| HAM-D† | ||
| 6 weeks | 12.7 | 10.7 |
| 12 weeks | 8.5 | 6.2 |
| 52 weeks | 5.8 | 7.2 |
| BDI‡ | ||
| 6 weeks | 19.7 | 15.1 |
| 12 weeks | 12.2 | 11.8 |
| 52 weeks | 9.6 | 11.5 |
| CIS§ | ||
| 6 weeks | 19.0 | 14.0 |
| 12 weeks | 12.4 | 9.8 |
| 52 weeks | 8.2 | 11.5 |
| SAS∥ | ||
| 6 weeks | 2.3 | 2.3 |
| 12 weeks | 2.1 | 2.0 |
| 52 weeks | 1.8 | 2.1 |
Recommendations from Others
Of the treatment guidelines for depression reviewed, none commented on the use of psychosocial interventions performed by primary care physicians. The Department of Defense clinical practice guidelines for depression in primary care settings suggests that patient preference should be given consideration given that no difference in outcome has been found between psychotherapy and pharmacotherapy for mild to moderate depression.5 However, these guidelines are referring to more formal therapy, such as cognitive behavior therapy, and not merely psychosocial interventions. In addition, practitioner experience in delivering psychological interventions should be taken into account by the referral source because level of experience has been shown to influence treatment effectiveness.
Clinical Commentary
Most family physicians do not provide formal psychosocial interventions for a variety of reasons, such as lack of formal training, office time constraints, and insurance reimbursement issues. However, family physicians maintain an important and unique role in the delivery of comprehensive, longitudinal care to patients with depression. Family physicians are in an ideal position to manage depression because of the high lifetime prevalence of major depression (18.5 percent) among adults in the United States.6 Furthermore, conditions commonly treated in the primary care setting such as diabetes, hypertension, and coronary artery disease are associated with an increased risk of depression.7–9 Family physicians can provide a much-needed supportive role, which includes empathy, effective listening, and a personal relationship with the rest of the family. Therefore, even without proven effectiveness of psychosocial interventions by primary care providers, family physicians should continue to explore the psychosocial concerns of their patients and offer support, guidance, and proper referral, if indicated.