Test Your Knowledge on Depression in Adults – Six Common Questions (Plus answers with research citations!)

There is constant warfare among and between “experts” and  non-experts on the basic facts surrounding depression. This quiz does an excellent job of addressing these frequently debated main points — providing research-based answers. Please read to the end for answers and their sources!

Note: RCTs refers to “randomized controlled  trials,” the gold standard in medical research.

Also on this topic: “Do Antidepressants Work?” The Answer is Yes!

mental-health-bipolar-disorderQuestion 1. What proportion of people seen in primary care settings has a major depressive disorder?

  1.  About 1%
  2. About 5%–10%
  3. About 20%–30% 

Question 2. Which one of the following best reflects
the evidence on selective serotonin reuptake
inhibitors (SSRIs) for treating depression in adults?

  1.  There is good evidence that they are more effective than tricyclic antidepressants (TCAs)
  2. They are likely to be equally as effective as TCAs and monoamine oxidase inhibitors (MAOIs)
  3. Although there is public concern that abruptly stopping SSRIs is associated with withdrawal symptoms, there is no research evidence to show that such symptoms occur

Question 3. Which one of the following best reflects
the clinical evidence on cognitive therapy for treating
mild to moderate depression?

  1.  In RCTs, cognitive therapy was found to be much less effective than TCAs and phenelzine
  2. Several systematic reviews have found that cognitive therapy significantly improves depressive symptoms, but further RCTs are needed to show that the results are generalizable
  3. Cognitive therapy is no better than giving no treatment in older adults (over 55 years of age)

Question 4. Which one of the following best reflects
the evidence on St. John’s wort for treating mild to
moderate depression?

  1.  A systematic review of RCTs found that St. John’s wort was less effective than TCAs
  2.  A systematic review of RCTs found that St. John’s wort was less effective than SSRIs
  3. A systematic review found that St. John’s wort was more effective than placebo
  4. There is good evidence of the effectiveness of St. John’s wort in older adults

Question 5. Which one of the following interventions
is best proven in RCTs to be effective at inducing
remission in people with mild to moderate
depression?

  1.  Interpersonal psychotherapy (IPT)
  2. Problem solving therapy (PST)
  3. Befriending
  4. Exercise

Question 6. Which of the following best reflects the
evidence on combining antidepressant drugs with
psychological therapies for treating mild to moderate
depression?

  1.  There is no evidence that combining these treatments is superior to either antidepressants alone or psychological therapy alone
  2. Based on the best available evidence, combining these treatments is likely to be superior to either treatment alone

_______________________________________________________
ANSWERS with research citations

Answer 1. About 5%–10%
About 5%–10% of people seen in primary care settings has a
major depressive disorder [1,2].

1. Butler R, Carney S, Cipriani A, Geddes J, Hatcher S, et al. (2005) Depressive disorders. Clin Evid 14: 1–7.

2. Katon W, Schulberg H (1992) Epidemiology of depression in primary care.
Gen Hosp Psychiatry 14: 237–247.

Answer 2. SSRI medications (Prozac and others) are likely to be equally as effective as TCAs and monoamine oxidase inhibitors (MAOIs), older medications for depression

Three systematic reviews found no significant difference in
outcomes with three different kinds of antidepressant drug
(TCAs, SSRIs, or MAOIs) [1–3].
One RCT [4], plus additional observational data [5],
suggested that abrupt withdrawal of SSRIs was associated with
symptoms including dizziness, rhinitis, dysmenorrhea, and
somnolence.
1. Williams JW Jr, Mulrow CD, Chiquette E, Noel PH, Aguilar C, et al. (2000)
A systematic review of newer pharmacotherapies for depression in adults:
Evidence report summary: Clinical guidelines, part 2. Ann Intern Med 132:
743–756.
2. Geddes JR, Freemantle N, Mason J, Eccles MP, Boynton J (2000) SSRIs
versus other antidepressants for depressive disorder. Cochrane Database
Syst Rev 2: CD001851.
3. Anderson IM (2000) Selective serotonin reuptake inhibitors versus tricyclic
antidepressants: A meta-analysis of effi cacy and tolerability. J Affect Disord
58: 19–36.
4. Zajecka J, Fawcett J, Amsterdam J, et al. (1998) Safety of abrupt
discontinuation of fl uoxetine: A randomised, placebo-controlled study. J
Clin Psychopharmacol 18: 193–197.
5. Butler R, Carney S, Cipriani A, Geddes J, Hatcher S, et al. (2005) Depressive
disorders. Clin Evid 14: 1–7.

Answer 3. Several systematic reviews have found that
cognitive therapy significantly improves depressive
symptoms

Based on their analysis of the results of fi ve systematic
reviews, Butler and colleagues concluded that there was
good evidence for the effectiveness of cognitive therapy for
treating mild to moderate depression [1]. But they noted
that the generalizability of these studies is questionable
because of varying exclusion criteria in RCTs of cognitive
therapy [1].
In one systematic review [2] (involving six RCTs and
883 outpatients with mild to moderate depression), the
proportion of patients who went into remission was similar
for psychotherapy (predominantly cognitive therapy and
interpersonal therapy; 46.3%) and medication (TCAs and
phenelzine; 46.4%).
One systematic review of four poor-quality RCTs found
that cognitive therapy signifi cantly improved symptoms
compared with no treatment in people aged over 55 years in
an outpatient or community setting [3].
1. Butler R, Carney S, Cipriani A, Geddes J, Hatcher S, et al. (2005) Depressive
disorders. Clin Evid 14: 1–7.
2. Casacalenda N, Perry JC, Looper K (2002) Remission in major depressive
disorder: A comparison of pharmacotherapy, psychotherapy, and control
conditions. Am J Psychiatry 159: 1354–1360.
3. McCusker J, Cole M, Keller E, Bellavance F, Berard A (1998) Effectiveness
of treatments of depression in older ambulatory patients. Arch Intern Med
158: 705–712.

Answer 4. A systematic review found that St. John’s wort was
more effective than placebo.

A systematic review identifi ed 24 RCTs that compared St.
John’s wort versus placebo in 2,752 people with depression.
The review found that patients were more likely to respond
to St. John’s wort than to placebo (relative risk 1.55, 95% CI
1.42–1.7) [1].
The review identifi ed seven RCTs that compared St. John’s
wort versus TCAs in 1,231 people with depression. There was
no signifi cant difference in response rate between the two
treatments.
The review also identified six RCTs that compared St. John’s
wort versus SSRIs in 813 people with depression. There was
no signifi cant difference in response rate between the two
treatments.
A systematic literature search found no RCTs or systematic
reviews looking at the effectiveness of St. John’s wort
specifi cally in older adults [2].
1. Linde K, Mulrow CD (2000) St John’s wort for depression. Cochrane
Database Syst Rev 2: CD000448.
2. Butler R, Carney S, Cipriani A, Geddes J, Hatcher S, et al. (2005) Depressive
disorders. Clin Evid 14: 1–7.
June 2006 | Volume 3 | Issue 6 | e325
PLoS Medicine | http://www.plosmedicine.org 0003

Answer 5. Interpersonal psychotherapy (IPT) is the best intervention (other than antidepressant medications) for depression

Two systematic reviews of RCTs involving adults with mildto moderate depression found that psychological therapies (mainly IPT and cognitive therapy) were more likely tinduce remission over ten to 34 weeks than control (usual care, usual care plus placebo pill, or supportive therapy)A[1,2]. These reviews did not specifi cally report outcomes forIPT alone. One systematic review and one subsequent RCT

found that IPT was more effective than control (usual care) at
inducing remission [3,4].
A systematic literature search concluded that PST was of
“unknown effectiveness” in mild to moderate depression
[5]. The search found one systematic review that examined
psychological therapies, including four RCTs of PST [2].
The review did not specifi cally look at the effects of PST for
moderate depression but it found no signifi cant difference
between PST and placebo in people with mild depression.
One subsequent large RCT found that PST increased the
proportion of people who were not depressed at six months
compared with usual care, but there was no signifi cant
difference at one year [6]. Another smaller RCT found no
difference in symptoms at eight or 26 weeks between PST and
usual care for people presenting to general practitioners with
emotional disorders (mostly depression) [7].
The authors of the systematic literature search [5] identifi ed
one small RCT of befriending for depression [8] and
concluded that the RCT “provided insuffi cient evidence
to assess befriending in people with mild to moderate
depression.”
One systematic review identifi ed 14 RCTs of exercise for
mild to moderate depression and found limited evidence that
exercise may improve symptoms compared with no treatment
[9]. However, the review suggested that these results are
inconclusive because of methodological problems with the
trials (discussed in [5]).
1. Casacalenda N, Perry JC, Looper K (2002) Remission in major depressive
disorder: A comparison of pharmacotherapy, psychotherapy, and control
conditions. Am J Psychiatry 159: 1354–1360.
2. van Schaik DJF, van Marwijk HWJ, van der Windt DAWM, Beekman ATF, de
Haan M, et al. (2002) Effectiveness of psychotherapy for depressive disorder
in primary care. Tijdschrift voor Psychiatrie 44: 609–619.
3. Churchill R, Hunot V, Corney R, Knapp M, McGuire H, et al. (2001)
A systematic review of controlled trials of the effectiveness and costeffectiveness
of brief psychological treatments for depression. Health
Technol Assess 5: 1–173.
4. Bolton P, Bass J, Neugebauer R, Verdeli H, Clougherty KF, et al. (2003)
Group interpersonal psychotherapy for depression in rural Uganda: A
randomized controlled trial. JAMA 289: 3117–3124.
5. Butler R, Carney S, Cipriani A, Geddes J, Hatcher S, et al. (2005) Depressive
disorders. Clin Evid 14: 1–7.
6. Dowrick C, Dunn G, Ayuso-Mateos JL, et al. (2000) Problem solving
treatment and group psychoeducation for depression: Multicentre
randomised controlled trial. Outcomes of Depression International
Network (ODIN) Group. BMJ 321: 1450–1454.
7. Mynors-Wallis L, Davies I, Gray A, Barbour F, Gath D (1997) A randomised
controlled trial and cost analysis of problem-solving treatment for emotional
disorders given by community nurses in primary care. Br J Psychiatry 170:
113–119.
8. Harris T, Brown GW, Robinson R (1999) Befriending as an intervention
for chronic depression among women in an inner city. 1: Randomised
controlled trial. Br J Psychiatry 174: 219–224.
9. Lawlor DA, Hopker SW (2001) The effectiveness of exercise as an
intervention in the management of depression: Systematic review and metaregression
analysis of randomised controlled trials. BMJ 322: 763–767.

Answer 6. Combining these treatments (antidepressant medication and psychotherapy) is likely to be superior to either treatment alone

Two systematic reviews found that a combination of
antidepressants and psychological therapy improved
depressive symptoms compared with either treatment alone
[1,2]. The fi rst review involved 16 RCTs and 1,842 people with
depression [1]; the second review involved 17 RCTs (the total
number of patients was not recorded) [2]. One subsequent
poor-quality RCT found no signifi cant difference in response
rate between combination treatment with sertraline plus
interpersonal therapy versus sertraline alone [3]. A second
subsequent RCT found no signifi cant difference between
short term psychodynamic psychotherapy plus antidepressants
and antidepressants alone [4] (though subgroup analysis
found that combination therapy was more effective in people
with depression and a personality disorder [5]).

Copyright: © 2006 Gavin Yamey. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Gavin Yamey is Magazine Editor at PLoS Medicine. E-mail: gyamey@plos.org
Gavin Yamey
PLoS Medicine | http://www.plosmedicine.org 0002

 

 

One response to “Test Your Knowledge on Depression in Adults – Six Common Questions (Plus answers with research citations!)

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