Brief psychologic interventions, particularly nondirective counseling and cognitive-behavior therapy, have become popular in Great Britain as treatments for depression. Until now, no research evidence supported the wide-spread use of these therapies in general practice, although they have been validated in specialist treatment settings. Ward and colleagues recruited patients from 24 general practices in two major English cities to conduct a randomized, controlled trial of these psychologic treatments compared with the usual care for depression provided by physicians.
Participating physicians were asked to refer adult patients with clinical depression (with or without anxiety) and a Beck depression score of at least 14. Exclusions included recent psychologic therapy or antidepressant medication, significant suicidal risk and inability to complete study requirements. Patients were allowed to select their treatment, but agreement to randomization was strongly encouraged. Most patients were interested in the psychologic therapies, but few patients were willing to be randomized to usual care. The counselors agreed to use a manual and techniques developed by the researchers for a minimum of six and a maximum of 12 weekly sessions, each lasting about 50 minutes. Analysis of randomly-selected tapes of sessions was used to monitor quality and consistency of technique. Patients in the psychologic treatment groups were not encouraged to request antidepressant medication during the study. Similarly, physicians treating control patients were discouraged from referring these patients for psychologic therapy. Outcomes were assessed at four and 12 months by Beck scores and several rating scales for social adjustment, patient satisfaction, psychologic symptoms and other concerns.
More than 600 patients were referred to the study, but 163 were excluded and 137 selected their own treatment. Only two patients selected usual care by physicians, 81 patients selected cognitive-behavior therapy and 54 selected nondirective counseling. One hundred and ninety-seven patients were randomized to physician care (67 patients), cognitive-behavior therapy (63 patients) and nondirective counseling (67 patients). An additional 130 patients were randomized between cognitive-behavior therapy (71 patients) and nondirective counseling (59 patients). Follow-up was complete in 89 percent of patients at four months and in 81 percent at 12 months.
About 12 percent of patients did not attend any of the counseling sessions and about 28 percent used antidepressant medication during the trial. At four months, patients in all treatment groups showed clinical improvement. Patients randomized to psychologic therapy showed greater improvement in Beck scores than those randomized to usual treatment, but no significant difference was found between the two therapies. At 12 months, no differences were found between the three treatment randomization groups in clinical outcomes or patient satisfaction. In patients who selected their own treatment, no clinical differences were found, but patient satisfaction was higher in those who chose counseling compared with those in the cognitivebehavior group. In a separate analysis, the same authors compared the costs of the three strategies and found no significant differences in direct costs, production losses or societal costs between the three treatments at four or 12 months.
The authors conclude that psychologic therapy was an effective and cost-effective treatment for depression in the short term but after one year, no differences could be detected from usual care by physicians.
editor's note: In some parts of the United States, a controversy exists about the treatment of depression by family physicians and other primary care physicians. This study could become an important reference because it is worth noting the many cautions qualifying the conclusion that treatment provided predominately by counselors was more effective than that given by physicians in the short-term treatment of depression. Besides the obvious problems with a high drop-out rate and the use of medications by nearly one third of the “psychologically treated” patients, no information is provided about what constitutes “normal care” by the physicians. It surely does not automatically equate to merely prescribing antidepressant medications. Many family physicians incorporate psychologic support and modified cognitive therapy into care. Surely, the message of the study is that patients respond well to empathic, expert care. This care may incorporate pharmacologic and psychologic approaches, depending on patient characteristics and other factors. The data in this study certainly cannot support the further erosion of the role of primary care physicians in helping patients recover from depression.—a.d.w.