Medication Treatment Versus Cognitive Behavior Therapy

I was disturbed by the mega-analysis of studies of severely depressed outpatients by Robert J. DeRubeis, Ph.D., and colleagues (1), which concluded that cognitive behavior therapy is a treatment equivalent to medication therapy. First, of the four studies analyzed, three used imipramine and one nortriptyline—the latter in modest doses at best. Nevertheless, the authors generalized these two drugs to represent all antidepressant medications. Second, severity was determined by using summed scores on the Hamilton Rating Scale for Depression or the Beck Depression Inventory, as if those alone can tell us the factors most clinicians consider when characterizing a patient’s depression severity. For example, were most patients in these studies dysthymic or melancholic? Most clinicians would consider the latter or even major depression without melancholic features to be more severe, whereas they would consider dysthymia more chronic and resistant to medication. Other severity considerations might include the degree of anxiety or agitation, suicidal feelings, suspiciousness or outright delusions or perceptual disturbances, and a history of bipolarity. If we are to take the conclusions of Dr. DeRubeis et al. literally, then a depressed man over 60 years of age with early-morning insomnia, weight loss, mild cognitive problems, psychomotor retardation, and dysphoria is better off with cognitive behavior therapy than with antidepressants and their potential side effects. Does anyone really believe that?