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Nonpharmacological Versus Pharmacological Treatments for Adult Patients With Major Depressive Disorder


Gartlehner, G., Gaynes, B. N., Amick, H. R., Asher, G. N., Morgan, L., Coker-Schwimmer, E. J., ... Lohr, K. (2015). Nonpharmacological Versus Pharmacological Treatments for Adult Patients With Major Depressive Disorder. (Comparative Effectiveness Review, No. 161; No. 15(16)-EHC031-EF). Rockville, Maryland: Agency of Healthcare Research and Quality (AHRQ).


Major depressive disorder (MDD)1 is the most prevalent and disabling form of depression, affecting more than 16 percent of U.S. adults (lifetime).2 MDD can be characterized as mild, moderate, or severe based on symptom severity, functional impairment, and level of patient distress;1 in clinical trials, these distinctions are typically made by scores on a depressive rating instrument.3 Approximately one-third of patients with MDD are severely depressed,4 which is associated with depression that is harder to treat, as evidenced by more difficulty in achieving treatment response and remission.5 In any given year, nearly 7 percent of the U.S. adult population (approximately 17.5 million people in 2014) experience an episode of MDD that warrants treatment.2 Most patients receiving care obtain treatment in primary care settings,6 where second-generation antidepressants (SGAs) are the most commonly prescribed agents.7 Nonetheless, patients and clinicians may prefer other options, or at least want to be able to consider them. These include psychological interventions, complementary and alternative medicine (CAM) options, and exercise. The psychological interventions used to treat depressed patients include acceptance and commitment therapy, cognitive therapy (CT), cognitive behavioral therapy (CBT), interpersonal therapy, and psychodynamic therapies. Commonly used CAM interventions for the treatment of patients with MDD include acupuncture, meditation, omega-3 fatty acids, S-adenosyl-L-methionine (SAMe), St. John's wort, and yoga. While acupuncture requires a licensed professional for treatment, the other options may be used in conjunction with a trained provider or be self-administered. Exercise covers a broad range of activities; they can be done over varying durations of time and singly, in classes, or in informal groups. About 40 percent of patients treated with SGAs do not respond to initial treatment; approximately 70 percent do not achieve remission during the first-step treatment.8 Those who do not achieve remission following initial pharmacological treatment require a different treatment strategy. Accordingly, various other interventions—such as medication combinations, psychotherapy, or CAM treatments—are options for patients and clinicians.