What Is the Best Sequential Treatment Strategy in the Treatment of Depression? Adding Pharmacotherapy to Psychotherapy or Vice Versa?

Abstract

Background: Insufficient response to monotreatment for depression is a common phenomenon in clinical practice. Even so, evidence indicating how to proceed in such cases is sparse. Methods: This study looks at the second phase of a sequential treatment algorithm, in which 103 outpatients with moderately severe depression were initially randomized to either short-term supportive psychodynamic therapy (PDT) or antidepressants. Patients who reported less than 30% symptom improvement after 8 weeks were offered combined treatment. Outcome measures were the Hamilton Depression Rating Scale (HAM-D), the Clinical Global Impression of Severity and Improvement, the SCL-90 depression subscale and the EuroQOL questionnaire. Results: Despite being nonresponsive, about 40% of patients preferred to continue with monotherapy. At treatment termination, patients initially randomized to PDT had improved more than those initially receiving antidepressants, as indicated by the HAM-D and the EuroQOL, independently of whether the addition was accepted or not. Conclusions: Starting with psychotherapy may be preferable in mildly and moderately depressed outpatients. For patients who receive either PDT or antidepressants, combined therapy after early nonresponse seems to be helpful. Nevertheless, this sequential strategy is not always preferred by patients.

The Three-Month Effect of Mobile Internet-Based Cognitive Therapy on the Course of Depressive Symptoms in Remitted Recurrently Depressed Patients: Results of a Randomized Controlled Trial

“…[48]]. Telephone support is said to increase adherence [49], and our results indicate that, even with limited telephone support from therapists, an Internet-based intervention may generate appreciable adherence rates. However, this only held true for remitted/recovered patients and not for the depressed phase.…”

Two-Year Follow-Up after Treatment with the Cognitive Behavioral Analysis System of Psychotherapy versus Supportive Psychotherapy for Early-Onset Chronic Depression

“…In one study utilizing monthly maintenance sessions with the CBASP over the course of 1 year after acute treatment, the CBASP proved superior over “assessment-only sessions” [12]. Persistent benefits were also demonstrated if a sequential model integrating pharmacotherapy was endorsed [40, 41]. Another reason for the unexpectedly small differences between the therapies after 2 years may be that SP is a strong comparator including powerful common efficacy factors for psychotherapy [22], in comparison to a wait list control or assessment-only sessions.…”

Benefits of Sequentially Adding Cognitive-Behavioral Therapy or Antidepressant Medication for Adults With Nonremitting Depression

“…A related, less-common, sequential treatment model involves adding a second treatment, usually psychotherapy, to prevent recurrence after remission with the initial treatment (8). Remarkably, although most depressed patients prefer psychotherapy (14) and leading treatment guidelines recommend an evidence-based psychotherapy as an initial intervention for all but the most severely ill patients (15,16), only one prior randomized trial has examined the value of adding antidepressant medication to psychotherapy, finding improved outcomes among 17 non-responders to psychodynamic psychotherapy (17). Thus, the evidence base is very limited regarding whether adding an antidepressant to CBT non-remitters improves acute outcomes and protects against depression recurrence.…”