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When are Psychotherapy and Pharmacotherapy Combinations the Treatment of Choice for Major Depressive Disorder?

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Abstract

Treating major depressive disorder with the combination of psychotherapy and pharmacotherapy is highly valued by both psychiatrists and their patients. However, results of most systematic research studies suggest that this approach may be overvalued: evidence of additive benefits (in relation to the respective component therapies, alone) is meager. In this paper it is argued that the advantage of combined treatment may be limited to treatment of patients with more complex depressive disorders, including characteristics such as comorbidity, chronicity, treatment resistance, episodicity, and severity. Said another way, milder acute depressions, especially initial or sporadic episodes, probably do not warrant the routine use of psychotherapy and pharmacotherapy. By focusing attention on the patient subgroups most likely to show a true additive response to combined treatment, it may be possible to obtain maximum benefits from dwindling resources.

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REFERENCES

  1. American Psychiatric Association: Practice guideline for major depressive disorder in adults. American Journal of Psychiatry 150:1–26, 1993.

    Google Scholar 

  2. Persons JB, Thase ME, Crits-Christoph P: The role of psychotherapy in the treatment of depression. Archives of General Psychiatry 53:283–290, 1996.

    Google Scholar 

  3. Depression Guideline Panel: Clinical practice guideline number 5. Depression in primary care, vol. 2. Treatment of major depression (AHCPR Publication No. 93–0551). Rockville, U.S. Department of Health and Human Services Agency for Health Care Policy and Research, 1993.

    Google Scholar 

  4. Thase ME: Psychopharmacology in conjunction with psychotherapy, in Handbook of Psychological Change: Psychotherapy Processes and Practices for the 21st Century. Edited by Ingram R, Snyder RC. New York, John Wiley & Sons, in press.

  5. Thase ME: The role of axis II comorbidity in the management of patients with treatment resistant depression. Psychiatric Clinics of North America 19(2):287–309, 1996.

    Google Scholar 

  6. Joyce PR, Paykel ES: Predictors of drug response in depression. Archives of General Psychiatry 46:89–99, 1989.

    Google Scholar 

  7. Thase ME, Howland R: Refractory depression: relevance of psychosocial factors and therapies. Psychiatric Annals 24:232–240, 1994.

    Google Scholar 

  8. Thase ME, Greenhouse JB, Frank E, et al: Treatment of major depression with psychotherapy or psychotherapy-pharmacotherapy combinations. Archives of General Psychiatry 54:1009–1015, 1997.

    Google Scholar 

  9. Simons AD, Gordon JS, Monroe SM, et al: Toward an integration of psychologic, social, and biologic factors in depression: effects on course and outcome of cognitive therapy. Journal of Consulting and Clinical Psychology 63:369–377, 1995.

    Google Scholar 

  10. Thase ME, Friedman ES: Is psychotherapy, alone, an effective treatment for melancholia and other severe depressive states? Journal of Affective Disorders (in press).

  11. Elkin I, Shea MT, Watkins JT, et al: National Institute of Mental Health Treatment of Depression Collaborative Research Program: General effectiveness and treatments. Archives of General Psychiatry 46:971–982, 1989.

    Google Scholar 

  12. Thase ME, Simons AD, Cahalane J, et al: Severity of depression and response to cognitive behavior therapy. American Journal of Psychiatry 148:784–789, 1991.

    Google Scholar 

  13. Hollon SD, DeRubeis RJ, Evans MD, et al: Cognitive therapy and pharmacotherapy for depression singly and in combination. Archives of General Psychiatry 49:774–781, 1992.

    Google Scholar 

  14. Klein DF, Ross DC: Reanalysis of the National Institute of Mental Health Treatment of Depression Collaborative Research Program general effectiveness report. Neuropsychopharmacology 8:241–251, 1993.

    Google Scholar 

  15. Elkin I, Gibbons RD, Shea MT, et al: Initial severity and differential treatment outcome in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology 63:841–847, 1995.

    Google Scholar 

  16. Stewart JW, Garfinkel R, Nunes EV, et al: Atypical features and treatment response in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Clinical Psychopharmacology 18:429–434, 1998.

    Google Scholar 

  17. Thase ME, Buysse DJ, Frank E, et al: Which depressed patients will respond to interpersonal psychotherapy? The role of abnormal electroencephalographic sleep profiles. American Journal of Psychiatry 154:502–509, 1997.

    Google Scholar 

  18. Sotsky SM, Glass DR, Shea MT: Patient predictors of response to psychotherapy and pharmacotherapy: findings in the NIMH Treatment of Depression Collaborative Research Program. American Journal of Psychiatry 148:997–1008, 1991.

    Google Scholar 

  19. Riso L, Thase ME, Howland RH, et al: A prospective test of criteria for response, remission, relapse, recovery, and recurrence in depressed patients treated with cognitive behavior therapy. Journal of Affective Disorders 43:131–142, 1997.

    Google Scholar 

  20. Kendall PC, Kipnis D, Otto-Salaj L: When clients don't progress: Influences on and explanations for lack of therapeutic progress. Cognitive Therapy Research 16:269–281, 1992.

    Google Scholar 

  21. Buysse DJ, Tu XM, Cherry CR, et al: Pretreatment REM sleep and subjective sleep quality distinguish depressed psychotherapy remitters and nonremitters. Biological Psychiatry 45:205–213, 1999.

    Google Scholar 

  22. Thase ME, Simons AD, Reynolds CF III: Abnormal electroencephalographic sleep profiles in major depression. Association with response to cognitive behavior therapy. Archives of General Psychiatry 53:99–108, 1996.

    Google Scholar 

  23. Thase ME, Dubé S, Bowler K, et al: Hypothalamic-pituitary-adrenocortical activity and response to cognitive behavior therapy in unmedicated, hospitalized depressed patients. American Journal of Psychiatry 153:886–891, 1996.

    Google Scholar 

  24. Thase ME, Reynolds CF III, Frank E, et al: Polysomnographic studies of unmedicated depressed men before and after treatment with cognitive behavior therapy. American Journal of Psychiatry 151:1615–1622, 1994.

    Google Scholar 

  25. Thase ME, Fasiczka AL, Berman SR, et al: Electroencephalographic sleep profiles before and after cognitive behavior therapy of depression. Archives of General Psychiatry 55:138–144, 1998.

    Google Scholar 

  26. Frank E, Kupfer DJ, Perel JM, et al: Three-year outcomes for maintenance therapies in recurrent depression. Archives of General Psychiatry 47:1093–1099, 1990.

    Google Scholar 

  27. Kocsis JH, Friedman RA, Markowitz JC, et al: Maintenance therapy for chronic depression—a controlled clinical trial of desipramine. Archives of General Psychiatry 53:769–776, 1996.

    Google Scholar 

  28. Reynolds CF III, Frank E, Perel JM, et al: Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression. A randomized controlled trial in patients older than 59 years. Journal of the American Medical Association 182:39–45, 1999.

    Google Scholar 

  29. Evans MD, Hollon SD, DeRubeis RJ, et al: Differential relapse following cognitive therapy and pharmacotherapy for depression. Archives of General Psychiatry 49:802–808, 1992.

    Google Scholar 

  30. Blackburn IM, Moore RG: Controlled acute and follow-up trial of cognitive therapy and pharmacotherapy in out-patients with recurrent depression. British Journal of Psychiatry 171:328–334, 1997.

    Google Scholar 

  31. Spanier C, Frank E, McEachran AB, et al: The prophylaxis of depressive episodes in recurrent depression following discontinuation of drug therapy: integrating psychological and biological factors. Psychological Medicine 26:461–475, 1996.

    Google Scholar 

  32. Fava G, Grandi S, Zielezny M, et al: Cognitive behavioral treatment of residual symptoms in primary major depressive disorder. American Journal of Psychiatry 151:1295–1299, 1994.

    Google Scholar 

  33. Fava GA, Grandi S, Zielezny M, et al: Four-year outcome for cognitive behavioral treatment of residual symptoms in major depression. American Journal of Psychiatry 153:945–947, 1996.

    Google Scholar 

  34. Fava GA, Rafanelli C, Grandi S, et al: Six-year outcome for cognitive behavioral treatment of residual symptoms in major depression. American Journal of Psychiatry 155:1443–1445, 1998.

    Google Scholar 

  35. Dashevsky BA, Kramer M: Behavioral treatment of chronic insomnia in psychiatrically ill patients. Journal of Clinical Psychiatry 59:693–699, 1998.

    Google Scholar 

  36. Cochran SD: Preventing medical noncompliance in the outpatient treatment of bipolar affective disorders. Journal of Consulting and Clinical Psychology 52:873–878, 1984.

    Google Scholar 

  37. Bowers WA: Treatment of depressed in-patients Cognitive therapy plus medication, relaxation plus medication, and medication alone. British Journal of Psychiatry 156:73–78, 1990.

    Google Scholar 

  38. Miller IW, Norman WH, Keitner GI: Cognitive-behavioral treatment of depressed inpatients: six-and twelve-month follow-up. American Journal of Psychiatry 146:1274–1279, 1989.

    Google Scholar 

  39. Clarkin JF, Glick ID, Haas GL, et al: A randomized clinical trial of inpatient family intervention. V. Results for affective disorders. Journal of Affective Disorders 18:17–28, 1990.

    Google Scholar 

  40. Miller IW, Norman WH, Keitner GI: Treatment response of high cognitive dysfunction depressed inpatients. Comprehensive Psychiatry 30:62–71, 1990.

    Google Scholar 

  41. Thase ME, Rush AJ, Kaspar S, Nemeroff C: Tricyclics and newer antidepressant medications: treatment options for treatment resistant depressions. Depression 152:152–168, 1995.

    Google Scholar 

  42. Fava GA, Savron G, Grandi S, et al: Cognitive-behavioral management of drug-resistant major depressive disorder. Journal of Clinical Psychiatry 58:278–282, 1997.

    Google Scholar 

  43. Goldman W, McCulloch J, Cuffel B, et al: Outpatient utilization patterns of integrated and split psychotherapy and pharmacotherapy for depression. Psychiatric Services 49:477–482, 1998.

    Google Scholar 

  44. Dewan M: Are psychiatrists cost-effective? An analysis of integreated versus split treatment. American Journal of Psychiatry 156:324–326, 1999.

    Google Scholar 

  45. Blackburn IM, Bishop S, Glen AIM, et al: The efficacy of cognitive therapy in depression: a treatment trial using cognitive therapy and pharmacotherapy, each alone and in combination. British Journal of Pyschiatry 139:181–189, 1981.

    Google Scholar 

  46. Teasdale JD, Fennell MJV, Hibbert GA, et al: Cognitive therapy for major depressive disorder in primary care. British Journal of Psychiatry 144:400–406, 1984.

    Google Scholar 

  47. Schulberg HC, Block MR, Madonia MJ, et al: Treating major depression in primary care practice. Eight-month clinical outcomes. Archives of General Psychiatry 53:913–919, 1996.

    Google Scholar 

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  1. University of Pittsburgh School of Medicine, U.S.A

    Michael E. Thase (Professor of Psychiatry)

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Thase, M.E. When are Psychotherapy and Pharmacotherapy Combinations the Treatment of Choice for Major Depressive Disorder?. Psychiatr Q 70, 333–346 (1999). https://doi.org/10.1023/A:1022042316895

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