Does combining psychotherapy and drug therapy for depression work better than either alone?

Whether psychotherapy, medication, or both should be used in the treatment of depression should always be considered on a case-by-case basis. That being said, studies dating back to the 1970s have shown that combining psychotherapy and drug therapy is usually more effective than employing either treatment alone.

What, specifically, are the benefits to combined treatment?

Numerous research studies have provided evidence for the following benefits of combined treatment over single-modality treatment:

  • Improved short-term recovery rates (Mintz, 2017)
  • Faster treatment response (Bowers, 1990)
  • Improved long-term recovery rates (Fava et al., 1998)
  • Decreased relapse rates (Paykel et al., 1999; Teasdale et al., 2000)
  • Improved long-term social functioning (Klerman et al., 1974)
  • Greater patient satisfaction (Seligman, 1995; de Jonghe et al., 2001)
  • Lower long-term health and social service costs (Browne et al., 2002; Goldman et al., 1998)

Who are the best candidates for combined treatment?

According to research, patients with these features are most likely to benefit from a combined approach:

  • Patients with severe depression (Bowers, 1990; Miller et al., 1989; Thase et al., 1997)
  • Patients with endogenous (non-situational) depression (Prusoff et al., 1980)
  • Patients with chronic depression (Keller et al., 2000; Hellerstein et al., 2001)
  • Patients with dysfunctional cognitions (Miller et al., 1990)
  • Those who respond incompletely to psychotherapy or drug therapy alone (Thase et al., 1997; Fava et al., 1994)

Why does combined treatment often work better?

Science is still unraveling why combined treatment for depression works better than psychotherapy or drug therapy alone.

Some researchers speculate that an additive effect may result from each modality addressing different symptoms domains — with social and cognitive aspects of depression being better helped by psychotherapy, and neurovegetative symptoms of depression being more quickly ameliorated by drug therapy. There is some evidence for this hypothesis, with functional neuroimaging studies (e.g., Goldapple et al., 2004) showing that medication effects develop “bottom up” (emanating from the brain stem upward), while psychotherapy effects emerge in a “top down” fashion (spreading downward from the frontal cortex).

Interaction effects are also likely. For example, patients may be better able to take advantage of psychotherapy when treatment-interfering symptoms (e.g., apathy, fatigue, lack of motivation, poor concentration) are decreased through medication. There is also evidence that suggests antidepressant use may make for more malleable neural networks, which may, in turn, allow for more rapid learning in psychotherapy. Psychotherapy may also help improve medication compliance, which would also be likely to improve outcome.

References

Mintz, D. (2017). Combining drug therapy and psychotherapy for depression. Psychiatric Times, 23(11).

Sammons, M. T., & McGuinness, K. M. (2015). Combining psychotropic medications and psychotherapy generally leads to improved outcomes and therefore reduces the overall cost of care. The Tablet.