Cognitive therapy added to medications beneficial in some patients with depression

About one-third of people with depression derive benefit from adding cognitive therapy to treatment with antidepressant medication, according to a study published in JAMA Psychiatry.

Steven D. Hollon of the psychology department of Vanderbilt University in Nashville, Tennessee, and colleagues studied a total of 452 adult outpatients with chronic or recurrent major depressive disorder (MDD). The outpatients participated in a trial conducted in research clinics at 3 university medical centers in the United States. The patients were randomly assigned to antidepressant medication treatment alone or cognitive therapy combined with antidepressant treatment. Treatment was continued for up to 42 months until recovery was achieved.

“All patients were treated for as long as was necessary-up to 3 years-with an flexible and aggressive approach to medication treatment designed to maximize recovery,” said Hollon. “Patients were treated with whatever medication(s) seemed most appropriate clinically, pushing the dose rapidly until the patient met criteria for remission and augmenting or switching away after a reasonable time at maximally tolerated dose.”

Non-remitting patients were taken through each of the existing classes of antidepressants (SSRIs, SNRIs, TCAs, MAOIs) until remission and subsequent recovery were achieved. Half the patients also received cognitive therapy in a flexible and aggressive fashion.

“This was perhaps the most clinically sophisticated approach to medication and combined treatment ever implemented in the treatment literature and wholly consistent with the notion of personalized medicine,” according to Hollon.

Combined treatment with cognitive therapy enhanced recovery for non-chronic patients with more severe depressions (about one-third of the sample) but a considerable amount (30% increment) over medication treatment alone; non-chronic patients with less severe depressions (about a third of the sample) did comparably well in each condition and chronic patients regardless of severity (the final third of the sample) did comparably less well in each condition

“Combined treatment is more expensive than medication treatment but appears to enhance recovery for only the third of the patients who are not chronic but have more severe depressions,” said Hollon. “Those patients should receive the combination whereas there is no clear advantage providing it for the other patients.”

About a third of depressed patients (non-chronic severe) derive a big benefit from combined treatment (about a 30% increment over medications alone) whereas there is little indication of incremented benefit for the rest, according to the authors.