This publication is provided for historical reference only and the information may be out of date.
Focus of Research for Clinicians
In response to a request from the public, a systematic review of 63 clinical studies published between January 1980 and November 2010 examined the comparative effectiveness, benefits, and adverse effects of nonpharmacologic interventions for treatment-resistant depression (TRD) in adults. The full report, listing all studies, is available at www.effectivehealthcare.ahrq.gov/trd.cfm. This summary, based on the full report of research evidence, is provided to inform discussions of options with patients and to assist in decisionmaking along with consideration of a patient's values and preferences. However, reviews of evidence should not be construed to represent clinical recommendations or guidelines.
Background
Among patients who receive appropriate treatment for major depressive disorder, about 50 percent will not adequately respond. Patients who do not respond to at least two adequate antidepressant trials are considered to have TRD for the purpose of this report.
Patients with TRD are significantly less likely to respond to subsequent medications and thus may require nonpharmacologic treatments, which have traditionally included electroconvulsive therapy (ECT) and psychotherapies such as cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). Newer nonpharmacologic approaches for major depressive disorder have broadened potential options to include repetitive transcranial magnetic stimulation (rTMS) and vagus nerve stimulation (VNS). Descriptions of these treatments are available below in Table 1.
Current evidence indicates that ECT has a role in the treatment of people with depression and in certain subgroups. The current role for ECT in depression is for treatment resistance or intolerance and for suicidality. Recently, trials have focused on the newer treatments rTMS and VNS. The systematic review focused on the effectiveness of the various nonpharmacologic options compared with each other and with pharmacotherapy, and also evaluated the efficacy of rTMS and VNS.
Conclusion
Comparative clinical research on nonpharmacologic treatments for TRD is in its infancy. Few direct comparisons between nonpharmacologic options were available, and all available evidence involving direct comparisons was either insufficient or of low strength. Within this limited evidence base, comparative outcomes for both ECT and rTMS are similar, with no apparent synergistic effect from combining these therapies. Evidence suggests that rTMS is effective in reducing depressive severity and producing response and remission over sham treatment. The effectiveness of ECT was not addressed in the review. No benefit was seen for VNS over sham treatment. Evidence regarding adverse effects is limited.
Clinical Bottom Line
Table 1
Descriptions of Nonpharmacologic Treatments Studied.
Table 2
General Adverse Effects Associated With Nonpharmacologic Therapies. The information below is generally reported and was not critically reviewed in the source report.
Gaps in Knowledge
- Information about health-related outcomes that concern quality of life or levels of functional impairment is substantially missing from current studies.
- Few studies compare nonpharmacologic interventions with each other or with pharmacologic interventions. Moreover, the comparative effectiveness of combined treatment interventions has not been evaluated.
- Almost no direct evidence exists on how the comparative effectiveness of nonpharmacologic treatments might differ as a function of symptom subtypes or for subgroups defined by sociodemographic characteristics (e.g., age) or by coexisting medical conditions (e.g., depression following a stroke or a myocardial infarction; perinatal depression).
- The following shortcomings of evaluated studies may limit the applicability or generalizability of some findings:
- Inconsistent definitions of TRD
- Inconsistent reporting of measured outcomes
- Short followup periods
- Limited, short-term, variable, and inconsistent adverse event reporting
What To Discuss With Patients and Caregivers
- The definition of TRD and why it may need different forms of treatment.
- The potential benefits and adverse events associated with nonpharmacologic treatment options.
- The patient's values and preferences regarding the trade-offs between the benefits and harms of the various treatment options.
- The availability of nonpharmacologic treatment options.
Resource for Patients and Caregivers
Therapies for Treatment-Resistant Depression, A Review of the Research is a free companion to this clinician research summary for patients and caregivers. It covers:
- A description of TRD, its symptoms, and why treatment may feel frustrating.
- Descriptions of the types of treatments, how they work, and potential side effects.
- Questions to guide a discussion with you about treatment options.
Ordering Information
For electronic copies of Therapies for Treatment-Resistant Depression, A Review of the Research, this clinician research summary, and the full systematic review, visit www.effectivehealthcare.ahrq.gov/trd.cfm. To order free print copies, call the AHRQ Publications Clearinghouse at 800-358-9295.
Source
The information in this summary is based on Nonpharmacologic Interventions for Treatment-Resistant Depression in Adults, Comparative Effectiveness Review No. 33, prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. HHSA-290-02-0016-I for the Agency for Healthcare Research and Quality, September 2011. Available at www.effectivehealthcare.ahrq.gov/trd.cfm. This summary was prepared by the John M. Eisenberg Center for Clinical Decisions and Communications Science at Baylor College of Medicine, Houston, TX.
Publication Details
Author Information and Affiliations
Authors
John M. Eisenberg Center for Clinical Decisions and Communications Science1.Affiliations
Publication History
Issued: March 19, 2012.
Copyright
Publisher
Agency for Healthcare Research and Quality (US), Rockville (MD)
NLM Citation
John M. Eisenberg Center for Clinical Decisions and Communications Science. Nonpharmacologic Interventions for Treatment-Resistant Depression in Adults. 2012 Mar 19. In: Comparative Effectiveness Review Summary Guides for Clinicians [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2007-.