Sequential Combination of Pharmacotherapy and Psychotherapy in Major Depressive Disorder

Abstract

IMPORTANCEThe sequential model emerged from the awareness that the persistence of residual symptoms and the frequent occurrence of psychiatric comorbidity were both associated with poor long-term outcome of major depressive disorder (MDD).OBJECTIVE To conduct an updated meta-analysis to examine the association of the sequential combination of pharmacotherapy and psychotherapy with reduced risk of relapse and recurrence in MDD.DATA SOURCES Keyword searches were conducted in PubMed, PsycInfo, Web of Science, and the Cochrane Library from inception of each database through November 2019. Reference lists from relevant studies were examined using the following keywords: sequential treatment, drugs and psychotherapy, combined treatment, continuation or maintenance, relapse or recurrence and prevention, and depress* or major depress*, selecting adults and randomized controlled trials as additional limits. Authors of selected articles were contacted if needed.STUDY SELECTION Randomized clinical trials examining the effectiveness of the sequential use of psychotherapy following response to acute-phase pharmacotherapy in the treatment of adult remitted patients with MDD were selected independently by 2 reviewers. DATA EXTRACTION AND SYNTHESISThe methods used fulfilled the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data extraction and methodologic quality assessment were conducted independently by the reviewers. Examination of the pooled results was performed based on the random-effects model. Heterogeneity between study results and likelihood of significant publication bias were assessed. Sensitivity analyses and meta-regressions were also run. MAIN OUTCOMES AND MEASURESThe primary outcome measures were relapse or recurrence rates of MDD, as defined by study investigators, at the longest available follow-up. RESULTSSeventeen randomized clinical trials met criteria for inclusion in the meta-analysis, with 1 study yielding 2 comparisons (2283 patients overall, with 1208 patients in a sequential treatment arm and 1075 in a control arm). The pooled risk ratio for relapse/recurrence of MDD was 0.84 (95% CI, 0.74-0.94), suggesting a relative advantage in preventing relapse/recurrence for the sequential combination of treatments compared with control conditions. CONCLUSIONS AND RELEVANCEThe results of this systematic review and meta-analysis indicate that the sequential integration of psychotherapy following response to acute-phase pharmacotherapy, alone or combined with antidepressant medication, was associated with reduced risk of relapse and recurrence in MDD. The preventive value of the sequential strategy relies on abatement of residual symptoms and/or increase in psychological well-being. The steps for implementing the sequential approach in remitted patients with recurrent MDD are provided.

Impact of Repetitive Transcranial Magnetic Stimulation (rTMS) on Theory of Mind and Executive Function in Major Depressive Disorder and Its Correlation with Brain-Derived Neurotrophic Factor (BDNF): A Randomized, Double-Blind, Sham-Controlled Trial

“…MDD often results in negative interpersonal experience which, in turn, usually causes depressed subjects to isolate themselves, perpetuating their depression, and which can precede and increase depressive symptomatology [5,6]. These symptoms have been demonstrated to involve the limbic system and prefrontal cortex (PFC), especially the amygdala and the hippocampus [7].…”

When Anxiety and Depression Coexist: The Role of Differential Diagnosis Using Clinimetric Criteria

“…In addition, the rapidity of symptom onset may herald further deterioration [27] and the impaired energy and motivation levels may hinder exposure homework, which is necessary for overcoming agoraphobic fears. The other option would be that of endorsing a sequential combination of treatment, using an antidepressant first and adding CBT when remission from depression occurs, with subsequent tapering and discontinuation of the antidepressant [35]. In the case of mild depression, another option would be a sequential combination of treatments which includes a benzodiazepine [36] first and CBT when improvement from panic attacks occurs, with subsequent tapering and discontinuation of the benzodiazepine.…”

“…In the case of mild depression, another option would be a sequential combination of treatments which includes a benzodiazepine [36] first and CBT when improvement from panic attacks occurs, with subsequent tapering and discontinuation of the benzodiazepine. In the case of this patient the first sequential model was used [35], with tapering and discontinuation of the antidepressant medication. Since the patient did not reach a full recovery after CBT, well-being therapy (WBT) [37, 38], a short-term psychotherapeutic strategy that pursues self-observation of instances of well-being, was added [39].…”

“…A sequential strategy based on the use of pharmacotherapy in the acute phase of depression and a psychotherapeutic approach in its residual phase has been developed [60] (online suppl. Table S3) and was found to be a viable strategy for preventing relapse in major depressive disorder in a number of randomized controlled trials [35]. In this model, psychotherapy addresses problems and symptoms that were unaffected by the drug treatment and is often different from first-line approaches (e.g., WBT, mindfulness-based cognitive therapy) [35].…”

Clinimetric Perspectives in Clinical Psychology and Psychiatry

“…These stations are a pause for verification or change to another direction [16]. Transfer stations have been suggested as repeated assessments after each line of treatment has been completed in the framework of the sequential treatment model, an intensive, two-stage approach, which includes the use of one treatment for the acute phase of a mental illness and of another treatment (either pharmacological or nonpharmacological) to address the residual symptomatology that the other treatment was unable to affect [17].…”