Combined Psychotherapy, Antidepressants More Effective Than Medication Alone

Paula Moyer, MA

May 06, 2004

May 6, 2004 (New York) — Supportive psychotherapy combined with antidepressant medication is more effective than pharmaceutical monotherapy in treating depression, especially in more severe cases, according to findings presented here at the 157th annual meeting of the American Psychiatric Association (APA).

"As psychiatrists, we know that combined treatment is inherently better, but we haven't proven it," said Michael T. Thase, MD, in a presentation. "New studies are showing that psychotherapy improves medical adherence, enhances patients' ability to cope with stressors, and improves their social skills and hedonic capacity." Dr. Thase is a professor of psychiatry at the University of Pittsburgh Medical Center in Pennsylvania.

One study of patients with depression compared the outcomes of 167 patients who were randomized to receive either combination psychotherapy and antidepressant pharmacotherapy (n = 83) or pharmacotherapy alone (n = 84). Of the patients in the combined therapy group, 72% experienced a remission of their depression symptoms compared with 57% of patients in the monotherapy group.

In a separate study that focused on severe, recalcitrant depression, more than 60% of patients on combined therapy experienced remission after six months of treatment. In the treatment of patients with bipolar disorder, family-focused psychotherapy reduced the risk of relapse from the typical 90% to 60%. "We are starting to get clear-cut evidence that psychotherapy pays for itself," Dr. Thase said.

"Combined therapy particularly improves outcomes in patients with severe depression and in those with chronic and recurrent depression," he told Medscape in an interview. "We also see this in patients with bipolar mood disorders. These studies show the cost-effectiveness of using psychotherapy in difficult cases. It is unknown still whether the type of psychotherapy is important, he said, adding that most practitioners use an "eclectic blend" of therapeutic styles.

Although antidepressant therapy is effective, it also has limitations, Dr. Thase noted. Patients may have resistant symptoms; nonadherence is endemic; and "medications don't replace a lifetime of maladaptive learning." Conversely, skeptics about psychotherapy's benefits call it an "elaborate placebo." Its limitations include poor quality control and limited efficacy as a monotherapy for severe depression. In addition, psychotherapy requires patient motivation and is often conducted for months without an objective benefit, he said.

"We need to be more effective and conscientious in the use of psychotherapy," Dr. Thase said. "If there is no improvement in six weeks, it is unlikely that there will be marked improvement after that." The hallmarks of effective combined treatment include a clear rationale for both treatments, clear treatment goals, and a tailored therapeutic approach. If treatment is split, the team should consist of a psychotherapist and pharmacotherapist who have compatible approaches, mutual respect, and who reinforce to the patient the value of both modalities.

"Dr. Thase's presentation is representative of an evolving project by the APA to restore psychotherapy as a cornerstone of psychiatric treatment," said Barton J. Blinder, MD, the moderator of the session, in an interview. Dr. Blinder is a clinical professor of psychiatry at the University of California in Irvine. He noted that the research Dr. Thase presented helps address a need to have research that validates psychiatrists' assumption regarding the value of combined treatment.

"We're looking at the neurobiological basis of mental conflict and psychotherapeutic change. Brain imaging studies are helping us to show the ways that psychotherapy improves functioning," Dr. Blinder said. "We want to integrate these findings and develop a rational understanding of the brain and the individual." This understanding will help clinicians deliver combined treatment more effectively, he said.

APA 157th Annual Meeting: Abstract 69B. Presented May 4, 2004.

Reviewed by Gary D. Vogin, MD

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