Patients who don’t respond well to medication for depression are often referred for psychotherapy. But there has been little evidence that this actually works.A recent trial attempted to assess whether this method could help patients. Researchers assigned a group of 808 patients, all of whom had been chronical- ly depressed for more than two years, to one of five antidepressants based on an algorithm (possibilities included sertraline, escitalopram, bupropion, venlafaxine, or mirtazapine).Those who did not respond to the medication by 12 weeks (491 patients total) had their med- ication regimens optimized according to a predefined algorithm. In this algorithm (referred to as “MEDS” in the paper) patients with no response to the first medication were switched to a different antidepressant, while those with a partial response received augmentation with either bupropion or venlafaxine.These patients were then randomly assigned to one of three conditions: MEDS alone, MEDS plus supportive therapy, or MEDS plus a type of cognitive behavioral thera- py. Outcomes were measured after 12 weeks on the Hamilton depression scale, and there was no significant difference in either remission rates (average of 15%) or partial response rates (22.5%).Thus, sur- prisingly, adding psychotherapy offered no notable advantages over medication by itself (Kocsis JH et al., Arch Gen Psychiatry 2009;66:1178–1188).
TCPR's Take:Before we conclude that adding psychotherapy does not help patients with treatment resistant depression, it is important to note that the “medication only” patients received more clinician contact than is typical. These patients had, on average, 5.2 visits with their psychiatrists over the course of the 12-week study, a visit frequency of nearly every two weeks.These frequent visits could have boosted response to medication. Also, the patients in this study were apparently skeptical of the benefits of psychotherapy—the authors reported that participants often “required considerable convincing” that psy- chotherapy was valuable. Finally, these results were specific to treatment-resist- ant depression; a prior meta-analysis found that adding psychotherapy at the start of depression treatment is associated with better outcomes than medication alone (Pampallona S et al., Arch Gen Psychiatry 2004;61:71–719).
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