Psychotherapy or medication for depression? Using individual symptom meta-analyses to derive a Symptom-Oriented Therapy (SOrT) metric for a personalised psychiatry

• Type of Material: Article
• Authors: Nils Kappelmann, Max Planck Institute of Psychiatry; Martin Rein, Max Planck Institute of Psychiatry; Julia Fietz, Max Planck Institute of Psychiatry; Helen Mayberg, Emory University; Wade Craighead, Emory University; Boadie Dunlop, Emory University; Charles B. Nemeroff, University of Texas Austin; Martin Keller, Brown University; Daniel N. Klein, Stony Brook University; Bruce A. Arnow, Stanford University; Nusrat Husain, University of Manchester; Robin B. Jarrett, University of Texas Southwestern Medical Center; Jeffrey R. Vittengl, Truman State University; Marco Menchetti, University of Bologna; Gordon Parker, University of New South Wales; Jacques Barber, Adelphi University; Andre G. Bastos, Contemporary Institute of Psychoanalysis and Transdisciplinarity of Porto Alegre; Jack Dekker, Arkin Mental Health Care; Jaap Peen, Arkin Mental Health Care; Martin E. Keck, Max Planck Institute of Psychiatry; Johannes Kopf-Beck, Max Planck Institute of Psychiatry
• Language: English
• Date: 2020-06-05
• Publisher: BMC Publishing
• Publication Version: Final Published Version
• Copyright Statement: © The Author(s). 2020.
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1186/s12916-020-01623-9
• Title of Journal or Parent Work: BMC Medicine
• Volume: 18
• Issue: 1
• Start Page: 170
• End Page: 170
• Grant/Funding Information: We specifically thank the National Institute of Mental Health (NIMH) as sponsor of the Barber et al. (MH 061410 [JP Barber]), Jarrett et al. (MH-45043 & MH-38238 [RB Jarrett]), and McGrath et al. (R01 MH073719 [HS Mayberg], T32 GM08695 [CL McGrath], K23 MH086690 [BW Dunlop], & K23 MH077869 [PE Holtzheimer]) studies, as well as studies funded by the Australian National Health and Medical Research Council (#1037196 and #GNT1176689 [G Parker]).; This project is funded by the Max Planck Institute of Psychiatry. The MARS project was supported by grants of the German Federal Ministry of Education and Research (BMBF), project no. 01ES0811 (Molecular Diagnostics) and 01EE1401D (German Research Network for Mental Disorders).; PReDICT study was supported by the following National Institutes of Health grants: P50 MH077083; R01 MH080880; UL1 RR025008; M01 RR0039; and the Fuqua family foundations.; Forest Labs and Elli Lilly Inc. donated the study medications, escitalopram and duloxetine, respectively, and were otherwise uninvolved in the study design, data collection, data analysis, or interpretation of findings.
• Keywords: Psychotherapy; Precision psychiatry; Treating depression; Systematic review; Depression symptoms; Life Sciences & Biomedicine; Term psychodynamic therapy; Antidepressant medication; Interpersonal psychotherapy; Science & Technology; Primary care; Symptom-oriented therapy metric; Medicine, General & Internal; Problem solving treatment; Meta-analysis; Randomized controlled trial; Major depressive disorder; Double-blind; Cognitive behavioral therapy; Major depression; General & Internal Medicine
• Research Categories: Psychology, Cognitive; Biology, Neuroscience; Health Sciences, Rehabilitation and Therapy; Psychology, Behavioral

Abstract

Background Antidepressant medication (ADM) and psychotherapy are effective treatments for major depressive disorder (MDD). It is unclear, however, if treatments differ in their effectiveness at the symptom level and whether symptom information can be utilised to inform treatment allocation. The present study synthesises comparative effectiveness information from randomised controlled trials (RCTs) of ADM versus psychotherapy for MDD at the symptom level and develops and tests the Symptom-Oriented Therapy (SOrT) metric for precision treatment allocation. Methods First, we conducted systematic review and meta-analyses of RCTs comparing ADM and psychotherapy at the individual symptom level. We searched PubMed Medline, PsycINFO, and the Cochrane Central Register of Controlled Trials databases, a database specific for psychotherapy RCTs, and looked for unpublished RCTs. Random-effects meta-analyses were applied on sum-scores and for individual symptoms for the Hamilton Rating Scale for Depression (HAM-D) and Beck Depression Inventory (BDI) measures. Second, we computed the SOrT metric, which combines meta-analytic effect sizes with patients’ symptom profiles. The SOrT metric was evaluated using data from the Munich Antidepressant Response Signature (MARS) study (n = 407) and the Emory Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) study (n = 234). Results The systematic review identified 38 RCTs for qualitative inclusion, 27 and 19 for quantitative inclusion at the sum-score level, and 9 and 4 for quantitative inclusion on individual symptom level for the HAM-D and BDI, respectively. Neither meta-analytic strategy revealed significant differences in the effectiveness of ADM and psychotherapy across the two depression measures. The SOrT metric did not show meaningful associations with other clinical variables in the MARS sample, and there was no indication of utility of the metric for better treatment allocation from PReDICT data. Conclusions This registered report showed no differences of ADM and psychotherapy for the treatment of MDD at sum-score and symptom levels. Symptom-based metrics such as the proposed SOrT metric do not inform allocation to these treatments, but predictive value of symptom information requires further testing for other treatment comparisons.