These findings suggest that ADM may not always be the best choice for a first-line treatment depression. Given that the efficacy of ADM has been overstated in the published literature, that at least half of all MDD patients derive little specific pharmacological benefit from medication treatment, and that drugs provide no lasting benefit after their use is discontinued, a case can be made that the cognitive or behavioral interventions are at least as viable as medications as the preferred first-line treatments of choice for depression. That certainly would appear to be the case for patients with less severe depression for whom medications provide no specific pharmacological effect but who would benefit from the enduring effects of the psychosocial interventions without the side effects of medications. In fact, nonspecific processes common to any reasonable intervention may be sufficient to produce response in patients with less severe depressions; the psychosocial interventions are no more likely to separate from ‘‘placebo’’ in such patients than are the ADMs. For such patients, something appears to be better than nothing and it may no more matter that the therapist be sufficiently expert to produce a specific effect with respect to acute response than that ADM be pharmacologically active. This could mean that most therapists could do a credible job with most patients and that only the more severe (or chronic or comorbid) patients would require an expert therapist.
The situation with respect to patients with more severe depressions is somewhat more complex. The efficacy of CT appears to depend to a considerable extent upon the competence of the therapist, whereas the pharmacologically active component of medication treatment appears to offset a number of problematic behaviors on the part of the prescribing clinician. In the hands of an expert cognitive therapist, CT may be preferred to ADM because of its enduring effect and freedom from side effects. When a highly competent CT therapist is not readily available then ADM likely is to be preferred. Moreover, there may be advantages to staying on ADM that go beyond the prevention of depression; in the Penn/Vandy study we found that paroxetine had nearly twice the ‘‘true’’ drug effect on neuroticism that it had on depression. This suggests that ADM may have a specific effect on stress reactivity that makes life better even when depression is not at issue. Patients who are prone to stress reactivity may prefer to start and stay on SSRI medications if it also helps to deal with a life-long propensity toward neuroticism and its associated apprehension and irritability. CT had a similar but smaller effect on neuroticism and may take longer (if ever) to produce an effect of comparable magnitude.
BA should be easier to master than CT and therefore easier to disseminate. Nonetheless, it has yet to be tested outside of the site at which it was developed. Few treatments turn out to be as efficacious as they first appear to be in the initial trials at their centers of origin and it remains to be seen how BA fares at other sites in subsequent studies. It will be especially interesting to see if the initial indications of an enduring effect for BA hold up across multiple replications as they have for CT. That being said, if BA does prove to be as robustly efficacious as medications and as enduring as CT but easier to disseminate, then it might prove to be the optimal first line choice for the treatment of depression regardless of the severity or complexity of the depression.