Depression and low intensity interventions

Very interesting article in BMJ on depression rx (See depression resp to low intens interven bmj 2013 in dropbox), a meta-anal of 16 studies with 2470 pts. The standard of care in UK, per this article, is to stratify patients by degree of depression, and in those less severely depressed, provide "low intensity" psychological intervention, which is based on cognitive behavioral therapy but is provided through written materials or internet-delivered.  This is the first step of a stepped-care approach, which can step up to conventional high intensity intervention (12-16 therapy sessions of cognitive behav therap) if needed. However, the decision threshold of when to start with the low-intensity intervention is not so clear from the medical literature.  In this study/analysis, they looked at 2470 pts with depression. Turns out that some of these had moderate to severe depression and were still referred to the low-intensity group. And they followed the Beck Depression Inventory (BDI) or the Center for Epidemiologic Studies Depression Scale (CES-D).  They found:

 

-Those with more severe depression actually had the greatest change in their depression scale, including in pts with BDI scores up to 40

-Overall, these more severely depressed patients showed remarkable improvement with the low-intensity intervention.  However, they started out with much higher symptom score, so even lowering it a lot left many with persistent sx

 

They comment that "rates of current antidepressant use (where reported) ranged from 19% to 69%".  Not sure what the med use was in those who were in the moderate to severe category (i assume it would be higher????)

 

So, a few things:

1. many of my patients with moderate to severe depression refuse to go to counseling.  So, i just give them meds, watch them closely, and continue talking about counseling in subsequent visits (though the patients most often are still resistant).  This low-intensity intervention may well be a useful adjunct to the meds for these patients.  And there seems to be benefit of this low-intensity approach in those with milder forms of depression, which has several advantages (eg, not enough therapists to help all those with mild depression, costs alot, and perhaps it empowers patients more to do this low-intensity intervention since they do it on their own).  There really needs to be good quality RCTs before recommending this approach formally.

2. i personally would still strongly suggest the higher intensity counseling for those with mod to severe depression, pending well-conducted RCTs documenting that the low-intensity intervention is as good.

3. interesting that they did not look at the interaction between meds and efficacy of the psych intervention.  Makes it a bit hard to interpret results fully.

4. they refer to an Oxford guide to low intensity CBT interventions from the oxfotrd university press, 2010 for the print approach and an article in Plos ONE (2010:5:e13196) for the IT approach (their bibliog has lots of references, if you are interested to pursue further -- these are not readily available to me to comment further. Again, further formal studies would be great, since this may be a really great intervention for many patients.