No Added Benefit of Adjunctive Psychotherapy to Antidepressants Alone in Chronic Depression

Janis C. Kelly

November 16, 2009

November 16, 2009 — Adjunctive psychotherapy in combination with antidepressant medication appears to offer no additional therapeutic benefit in patients with chronic depression, a large, randomized, 12-week trial suggests.

Investigators at Weill Cornell Medical College in New York found that after 12 weeks of continued pharmacotherapy plus either brief supportive psychotherapy (BSP) or cognitive behavioral analysis system of psychotherapy (CBASP), outcomes were no better than if patients received medication alone.

"It would be fair to say that the approaches were equally effective," lead investigator James H. Kocsis, MD, told Medscape Psychiatry.

The study is published in the November issue of Archives of General Psychiatry.

Findings Contrary to Study Hypothesis

The trial included 491 patients with chronic depression. Participants had depressive symptoms for a minimum of 2 years without remission and met diagnostic criteria for double depression, chronic major depression, or recurrent major depression with incomplete recovery between episodes.

The study's main outcome measures were proportion of remitters, partial remitters, and nonresponders and change from baseline in the Hamilton Scale for Depression scores.

Participants were randomized to receive 12 weeks of continued pharmacotherapy plus CBASP, continued pharmacotherapy with BSP, or continued optimized pharmacotherapy alone.

At the end of the study period, the investigators found no statistically significant differences among the 3 treatment groups in the proportions of patients in remission, partial response, or nonresponse, suggesting, said Dr. Kocsis, that although chronic depression is often helped by medication, there is little evidence of added benefit with adjunctive psychotherapy.

"We were surprised. The results went against our hypotheses. We are interested in studying differential predictors of response to drugs versus psychotherapy. We think early life adversity and childhood maltreatment may be important in predicting need for psychotherapy," Dr. Kocsis said.

Dr. Kocsis also noted that current American Psychiatric Association treatment guidelines only address major depression and not chronic depression. "Perhaps they should develop separate guidelines for chronic depression," he said.

Convincing but Not Conclusive

Pim Cuijpers, PhD, who has published 2 meta-analyses of psychotherapies for chronic depression, described the Kocsis study as "sobering." Dr. Cuijpers is professor of clinical psychology, chair of the Department of Clinical Psychology, and vice-director of the EMGO Institute for Health and Care Research at VU University, Amsterdam, The Netherlands.

Dr. Cuijpers told Medscape Psychiatry that, although he finds these data convincing, they are not conclusive. "The conclusion that pharmacotherapy alone is just as good as combined treatments is not supported by the total body of research in this area," he said.

The Cuijpers' meta-analysis of psychotherapies for chronic depression, which is currently in press, concluded that combined treatments have a small benefit over pharmacotherapy alone.

"I do not think the Kocsis study [which was published after the meta-analysis was completed] would change the results of our meta-analysis if it had been included. Our meta-analysis, however, also shows that the results of psychotherapy are not very high in chronic depression," Dr. Cuijpers said.

The study was sponsored by the National Institute of Mental Health. All medications were donated by Forest Laboratories, GlaxoSmithKline, Organon Pharmaceuticals Inc, Pfizer Inc, and Wyeth Pharmaceuticals. Dr. Kocsis reports receiving research support from AstraZeneca, Burroughs Wellcome Trust, CNS Response Inc, Forest Pharmaceuticals, the National Institute on Drug Abuse, the National Institute of Mental Health, Pritzker Consortium, and Sanofi Aventis; participating on the speaker's bureau for AstraZeneca, Pfizer Inc, and Wyeth; and acting as a consultant to Wyeth.

Arch Gen Psychiatry. 2009;66:1178–1188.

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