A Systematic Review of Comparative Efficacy of Treatments and Controls for Depression

Background: Although previous meta-analyses have examined effects of antidepressants, psychotherapy, and alternative therapies for depression, the efficacy of these treatments alone and in combination has not been systematically compared. We hypothesized that the differences between approved depression treatments and controls would be small. Methods and Findings: The authors first reviewed data from Food and Drug Administration Summary Basis of Approval reports of 62 pivotal antidepressant trials consisting of data from 13,802 depressed patients. This was followed by a systematic review of data from 115 published trials evaluating efficacy of psychotherapies and alternative therapies for depression. The published depression trials consisted of 10,310 depressed patients. We assessed the percentage symptom reduction experienced by the patients based on treatment assignment. Overall, antidepressants led to greater symptom reduction compared to placebo among both unpublished FDA data and published trials (F = 38.5, df = 239, p<0.001). In the published trials we noted that the magnitude of symptom reduction with active depression treatments compared to controls was significantly larger when raters evaluating treatment effects were un-blinded compared to the trials with blinded raters (F = 2.17, df = 313, p<0.05). In the blinded trials, the combination of antidepressants and psychotherapy provided a slight advantage over antidepressants (p = 0.027) and psychotherapy (p = 0.022) alone. The magnitude of symptom reduction was greater with psychotherapies compared to placebo (p = 0.019), treatment-as-usual (p = 0.012) and waiting-list (p<0.001). Differences were not seen with psychotherapy compared to antidepressants, alternative therapies or active intervention controls. Conclusions: In conclusion, the combination of psychotherapy and antidepressants for depression may provide a slight advantage whereas antidepressants alone and psychotherapy alone are not significantly different from alternative therapies or active intervention controls. These data suggest that type of treatment offered is less important than getting depressed patients involved in an active therapeutic program. Future research should consider whether certain patient profiles might justify a specific treatment modality

Smaller loads reduce risk of back injuries during wine grape harvest

Hand-harvest work in wine grape vineyards is physically demanding and exposes workers to a variety of ergonomics risk factors. Analysis of these exposures together with data on reported work-related injuries points to the risk of back injury as a prevention priority, in particular the lifting and carrying of tubs of cut grapes (weighing up to 80 pounds) during harvest. Our study evaluated the effectiveness of an intervention — the use of a smaller picking tub — on the incidence of musculoskeletal symptoms among workers during two harvest seasons. Reducing the weight of the picking tub by about one-fifth to below 50 pounds resulted in a five-fold reduction in workers' postseason musculoskeletal symptom scores, without significant reductions in productivity

Mean Percentage Symptom Reduction from Un-blinded and Blinded Treatment Arms from Published Depression Trials Compared to Data from Pivotal Registration Depression Trials as Reported by the FDA.

<p>Red Bars Represent Un-Blinded Trial Arms Blue Bars Represent Blinded Trial Arms Yellow Represents Placebo Control Arms from Published Non-Registration trials Green Bars Represent Data from Pivotal Registration Trials The mean percentage symptom reduction was weighted by the number of assigned patients. Error Bars Represent 95% Confidence Intervals. Active treatment arms consist of combination antidepressant + therapy, antidepressants, psychotherapy, antidepressant therapy and alternative therapy. Control treatment arms consisted of placebo control, active intervention control, treatment-as-usual and waiting-list control. Blinded trials were operationally defined as those that utilized depression symptom raters that were blinded to treatment assignment of the patients.</p

Process of Exclusion of Trials Identified During Search of Depression Treatment Reviews and Analyses, and the Website by Cuijpers and Colleagues.

<p>Process of Exclusion of Trials Identified During Search of Depression Treatment Reviews and Analyses, and the Website by Cuijpers and Colleagues.</p

Percentage Symptom Reduction with Active Treatments and Controls among Depression Trials with a Blinded Rater.

*<p>Percentage symptom reduction values are weighted by number of patients per treatment arm for each active intervention and control for 56 blinded depression treatment trials with 171 treatment arms enrolling 6,227 patients.</p><p>Bolded text represents four active depression treatments. Italic text represents the four treatment controls.</p><p>k = number of treatment arms for each therapy type.</p><p>Probability values show the statistical significance of comparisons between the treatment or control on the vertical access versus treatment or control on the horizontal access.</p><p>NS = Not Significant.</p>a<p>Combination antidepressant therapy versus other treatments and controls.</p>b<p>Antidepressant therapy versus other treatments and controls.</p>c<p>Psychotherapy versus other treatments and controls.</p>d<p>Alternative therapy versus treatment controls.</p>e<p>Active intervention control versus treatment as usual and waiting-list controls.</p>f<p>Placebo versus other treatment controls.</p>g<p>Treatment as usual versus waiting list control.</p><p>Analysis of Variance F Value (163 df) = 11.99, p<0.001, statistical significance determined with Tukey’s Post Hoc Test of Least Significant Difference.</p