Antidepressant drugs and generic counselling for treatment of major depression in primary care: randomised trial with patient preference arms

Chilvers, Claire; Dewey, Michael; Fielding, Katherine; Gretton, Virginia; Miller, Paul; Palmer, Ben; Weller, David; Churchill, Dick; Williams, Idris; Bedi, Navjot; Duggan, Conor; Lee, Alan; Harrison, Glynn

doi:10.1136/bmj.322.7289.772

Cited by 236 publications

(157 citation statements)

References 11 publications

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“…Details of the trial methodology and clinical outcomes have been published elsewhere (6). Patients were randomized to either counseling or antidepressants.…”

Section: Methodsmentioning

confidence: 99%

Counseling Versus Antidepressant Therapy for the Treatment of Mild to Moderate Depression in Primary Care

Miller

Chilvers

Dewey

et al. 2003

Int J Technol Assess Health Care

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Objective: To compare the cost-effectiveness of generic psychological therapy (counseling) with routinely prescribed antidepressant drugs in a naturalistic general practice setting for a follow-up period of 12 months. Methods: Economic analysis alongside a randomized clinical trial with patient preference arm. Comparison of depression-related health service costs at 12 months. Cost-effectiveness analysis of bootstrapped trial data using net monetary benefits and acceptability curves. Results: No significant difference between the mean observed costs of patients randomized to antidepressants or to counseling (£342 vs £302, p = .56 [t test]). If decision makers are not willing to pay more for additional benefits (value placed on extra patient with good outcome, denoted by K , is zero), then we find little difference between the treatment modalities in terms of cost-effectiveness. If decision makers do place value on additional benefit (K > £0), then the antidepressant group becomes more likely to be cost-effective. This likelihood is in excess of 90% where decision makers are prepared to pay an additional £2,000 or more per additional patient with a good global outcome. The mean values for incremental net monetary benefits (INMB) from antidepressants are substantial for higher values ofConclusion: For a small proportion of patients, the counseling intervention (as specified in this trial) is a dominant cost-effective strategy. For a larger proportion of patients, the antidepressant intervention (as specified in this trial) is the dominant cost-effective strategy. For the remaining group of patients, cost-effectiveness depends on the value of K . Since we cannot observe K , acceptability curves are a useful way to inform decision makers.

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“…Details of the trial methodology and clinical outcomes have been published elsewhere (6). Patients were randomized to either counseling or antidepressants.…”

Section: Methodsmentioning

confidence: 99%

Counseling Versus Antidepressant Therapy for the Treatment of Mild to Moderate Depression in Primary Care

Miller

Chilvers

Dewey

et al. 2003

Int J Technol Assess Health Care

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“…Remission typically follows response by at least several weeks (O'Leary et al, 2000;Chilvers et al, 2001;Koran et al, 2001;Trivedi et al, 2001;Quitkin et al, 2003;Trivedi et al, 2006). Consequently, trials with remission as an end point may need to be longer.…”

Section: Clinical Trial Durationsmentioning

confidence: 99%

“…With medications, remission may begin within 4-12 weeks (or longer) after beginning treatment (O'Leary et al, 2000;Chilvers et al, 2001;Trivedi et al, 2001Trivedi et al, , 2006Quitkin et al, 2003).…”

Section: Factors Affecting Remissionmentioning

confidence: 99%

Report by the ACNP Task Force on Response and Remission in Major Depressive Disorder

Rush¹,

Kraemer

Sackeïm

et al. 2006

Neuropsychopharmacol

605

489

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This report summarizes recommendations from the ACNP Task Force on the conceptualization of remission and its implications for defining recovery, relapse, recurrence, and response for clinical investigators and practicing clinicians. Given the strong implications of remission for better function and a better prognosis, remission is a valid, clinically relevant end point for both practitioners and investigators. Not all depressed patients, however, will reach remission. Response is a less desirable primary outcome in trials because it depends highly on the initial (often single) baseline measure of symptom severity. It is recommended that remission be ascribed after 3 consecutive weeks during which minimal symptom status (absence of both sadness and reduced interest/pleasure along with the presence of fewer than three of the remaining seven DSM-IV-TR diagnostic criterion symptoms) is maintained. Once achieved, remission can only be lost if followed by a relapse. Recovery is ascribed after at least 4 months following the onset of remission, during which a relapse has not occurred. Recovery, once achieved, can only be lost if followed by a recurrence. Day-to-day functioning and quality of life are important secondary end points, but they were not included in the proposed definitions of response, remission, recovery, relapse, or recurrence. These recommendations suggest that symptom ratings that measure all nine criterion symptom domains to define a major depressive episode are preferred as they provide a more certain ascertainment of remission. These recommendations were based largely on logic, the need for internal consistency, and clinical experience owing to the lack of empirical evidence to test these concepts. Research to evaluate these recommendations empirically is needed.

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“…Thus, the Bedi et al (13) and Chilvers et al (14) reports of two and twelve-month outcomes, respectively, with the same sample of mid-life depressed primary care patients found generic counseling and antidepressant medication to produce similar improvement rates regardless of whether the patient had personally selected the treatment or been randomized to it. However, this study was an unbalanced comparison as only patients refusing the randomized assignment were then offered their personal preference (13,14). Consequently, the group receiving their preferred treatment was compared to a heterogeneous group of patients, some of whom preferred the treatment to which they were randomized while others did not prefer it but participated in the treatment despite their dislike of it (either their preferences were not very strong or they tended towards adherence regardless of preference).…”

Section: Introductionmentioning

confidence: 99%

mentioning

confidence: 99%

Patients' Depression Treatment Preferences and Initiation, Adherence, and Outcome: A Randomized Primary Care Study

Raue¹,

Schulberg²,

Heo³

et al. 2009

Psychiatric Services

131

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Objective-We examined the association of treatment preferences with treatment initiation, adherence, and clinical outcome among depressed mid-life and elderly primary care patients.Methods-60 primary care participants meeting DSM-IV criteria for major depression were randomized to receive treatment congruent or incongruent with their primary stated preference. Participants received either 20 weeks of escitalopram as monitored by a care manager, or 12 weekly sessions of interpersonal psychotherapy followed by 2 monthly booster sessions. Adherence to treatment and depression severity were reassessed at weeks 4, 8, 12, and 24.Results-Participants expressed stronger preferences for psychotherapy than antidepressant medication. Preference strength was a more sensitive measure of outcomes than congruence versus incongruence of preference with the assigned treatment. Across age groups, preference strength was significantly associated with treatment initiation and 12-week adherence rate, but not with depression severity or remission.Conclusions-A continuous measure of preference strength may be a more useful measure in clinical practice than preferences per se. Future research should focus on whether and how greater facilitation of the patient-clinician treatment decision-making process influences clinical outcome.Treatments of depression in primary care settings are effective yet most depressed adults (1), particularly older ones (2), do not receive appropriate care. Even when guideline-based treatments are provided, patients often do not fully participate in them. Not surprisingly, therefore, randomized clinical trials have reported substantially poorer outcomes for "intent to treat" than "treatment completer" cohorts (3), indicating a need for strategies that maximize treatment participation.A patient's decision not to initiate or complete treatment may stem from disappointment or dissatisfaction with the treatment offered by the clinician. While medications are the predominant intervention offered depressed primary care patients, 50%-86% of them prefer a psychosocial intervention (4-7). Thus, many patients conceivably refuse treatment offered in primary care because psychotherapy is not an available option.In psychiatric outpatient settings, treatment preferences have been addressed through "negotiated treatment plans" whereby clinicians elicit patient requests and encourage their participation in treatment planning. Patient reports of greater participation in such negotiations have been associated with greater levels of satisfaction, sense of feeling helped, and adherence to treatment plans (8,9). Studies of mid-life patients in the primary care sector have endorsed the value of a negotiated treatment plan and the importance of patients playing active rather than passive roles in formulating it. Such participation enhances the patient's likelihood of initiating treatment and his/her satisfaction with it (10-12).Despite these benefits, the few studies examining treatment negotiation and clinical outcome have...

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Antidepressant drugs and generic counselling for treatment of major depression in primary care: randomised trial with patient preference arms

Cited by 236 publications

References 11 publications

Counseling Versus Antidepressant Therapy for the Treatment of Mild to Moderate Depression in Primary Care

Counseling Versus Antidepressant Therapy for the Treatment of Mild to Moderate Depression in Primary Care

Report by the ACNP Task Force on Response and Remission in Major Depressive Disorder

Patients' Depression Treatment Preferences and Initiation, Adherence, and Outcome: A Randomized Primary Care Study

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