Most psychiatrists believe that the combination of medication and
psychotherapy is the best option for treating moderate to severe major
depression. Studies are beginning to describe how each of those modalities
contributes its own benefits and why, when combined, those benefits add up to
more than the sum of the two
Michael Thase, M.D.: Psychotherapy "is pragmatic and can be made
personality relevant. In general, it works as well as, if not better than,
"Antidepressant therapy alone has its problems, including a high rate
of residual symptoms. Fifty percent of patients on antidepressants don't get
better," said Michael Thase, M.D., at APA's 2004 annual meeting last
month in New York City. The medical literature is starting to detail why that
is the case, he said. Thase is a professor of psychiatry at the University of
Pittsburgh School of Medicine and a leading researcher on the
psychopharmacology of mood disorders.
Patients' noncompliance with medications, he emphasized, "is
endemic." And certain skill deficits or traits aren't readily amenable
to drug therapy.
In contrast, several recent studies have shown that psychotherapy improves
a patient's adherence to medical therapy, can enhance the patient's ability to
cope with stressors, and improves social, cognitive, and problem-solving
"You can't treat a depressive temperament, lack of problem-solving
skills, cluster C personality disorders, or neuroticism very well with
medications," Thase pointed out. In fact, he added, these issues could
be predictors of a patient's poor response to medication therapy alone, as
well as demoralization and a lack of a solid psychosocial support system for
Psychotherapy "is usually time limited, focused, and structured. It
is pragmatic and can be made personality relevant," Thase said."
In general, it works as well as, if not better than,
However, psychotherapy does have its limits. It increases short-term
treatment expenses, requires patient motivation, and "can often go on
for months without any apparent benefit—especially in cases of more
With psychotherapy, Thase added, "you really have poor quality
control. Therapy simply varies a great deal from one therapist to another,
from one patient to another, and even from one session to another with the
same therapist and the same patient. With medications, the variable is always
Thase stressed that pharmacotherapy and psychotherapy are best done for a
particular patient by the same clinician. If therapy must be split, however,
it must be done with a clear rationale for both, along with specific and
separate goals for both.
"It must be a tailored therapeutic approach where the psychotherapist
and the pharmacotherapist act as a team. Both clinicians need to have
compatible psycho-education and, with mutual respect, reinforce both sides of
the therapeutic regimen."
Combined medication and psychotherapy, Thase said, ideally improves a
patient's adherence to medication therapy, targets residual symptoms, and
works to enhance coping, stress-reduction, and problem-solving skills, while
strengthening a patient's social network.
New research is beginning to highlight some of the physiological benefits
of combined treatment, compared with therapy or medication alone, Thase said.
Combined treatment appears to lead to decreased limbic activation, dampens the
hypothalamicpituitary axis, and improves glucose utilization in the prefrontal
cortex. Sleep is improved, and a patient's hedonic capacity is increased.
"We really don't yet know much about which therapies work best in
what particular situation," Thase concluded, "but studies are
showing that there is a high risk/high yield population for combined
treatment. For those with severe, recalcitrant depression, and more severe
mood disorders other than depression—such as bipolar disorder—a
patient's chance of remission may be increased as much as 60 percent."▪