Integrating CBT, Pharmacotherapy May Prevent Relapse in MDD

Patients with major depressive disorder (MDD) who participate in psychotherapy after responding to acute-phase pharmacotherapy may have a lower risk of relapse and recurrence when tapering antidepressants, according to a meta-analysis published October 20 in AJP in Advance.

Researchers from the University of Bologna in Italy and University of New York, Buffalo, performed a systematic review of randomized, controlled trials that examined the effectiveness of the administration of psychotherapy after successful response to acute-phase pharmacotherapy in the treatment of adults with MDD.

“The results of this meta-analysis provide new, important clinical insights into the role of psychotherapy in the treatment of depression,” said lead author Jenny Guidi, Ph.D., a professor of psychology and education sciences at the University of Bologna. “The sequential modality of integration of pharmacotherapy and psychotherapy appears to be a valuable therapeutic strategy for preventing relapse in major depressive disorder.”

For the study, Guidi and colleagues analyzed 13 trials (including 1,410 participants aged 18 and older with no history of comorbid psychiatric illness)—all of which involved cognitive-behavioral therapy (CBT) after an acute-phase of pharmacotherapy.

They found that patients who were randomly assigned to receive CBT while antidepressants were discontinued were significantly less likely to experience relapse or recurrence compared with those assigned to either clinical management during tapering of antidepressants or continuation of antidepressant medication.

The number needed to treat (NNT)—the average number of patients who need to be treated to prevent one unfavorable health outcome—for the CBT plus drug tapering/discontinuation group was 5 compared with an NNT of 10 among those who continued pharmacotherapy, suggesting a greater advantage associated with the sequential option of drug tapering/discontinuation in preventing relapse or recurrence than with continuation of antidepressants.

“The average depressed patient appears to express stronger preferences for psychotherapy than for antidepressant medications, a finding that is of considerable clinical importance given that treatment preference is a potent moderator of response to therapy,” the study authors wrote.

“There is urgent need for studies comparing continuation and discontinuation of antidepressant drugs during the application of the psychotherapeutic approach in the residual phase of depressive illness,” said Guidi. “There is also a need to compare different strategies—such as psychotherapy alone, pharmacotherapy alone, and their simultaneous or sequential integration in head-to-head comparisons. The efficacy of the sequential use of other well-established psychotherapies after response to pharmacotherapy need to be tested as well.”

The study was supported in part by Compagnia di San Paolo, a bank foundation in Italy. ■

“The Sequential Integration of Pharmacotherapy and Psychotherapy in the Treatment of Major Depressive Disorder: A Meta-Analysis of the Sequential Model and a Critical Review of the Literature” can be accessed here.