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CBT, pharmacotherapy equally effective for remission in depression

Study findings published in the American Journal of Psychiatry indicated that cognitive behavioral therapy and antidepressant medication appeared equally efficacious for achieving remission when sequentially combined in patients with nonremitting depression.

“The evidence base is limited regarding whether adding an antidepressant to the treatment regimen for patients whose depression has not remitted in response to CBT improves acute outcomes and protects against recurrence,” Boadie Dunlop, MD, department of psychiatry and behavioral sciences, Emory University School of Medicine, and colleagues wrote. “Further, it is uncertain whether the efficacy of sequential combination treatment differs by the order in which the psychotherapy and antidepressant medication treatments are conducted, and whether there are predictors for the efficacy of combination treatments.”

Researchers evaluated the acute and long-term outcomes resulting from both sequences of combination treatment with CBT and antidepressants in this phase 2 study. They also examined demographic, clinical and patient preference variables as potential predictors and moderators of outcomes.

In phase 1 of the study, patients with previously untreated major depression were randomly assigned to a 12-week course of CBT or antidepressant medication. In phase 2, participants who did not achieve remission with monotherapy received a second 12-week course of treatment, plus an additional complementary treatment. Specifically, researchers added escitalopram to initial treatment for participants who did not achieve remission with CBT (CBT plus medication group) and added CBT to initial treatment for those who did not achieve remission with an antidepressant (medication plus CBT group).

Overall, 112 patients who did not achieve remission with a monotherapy entered combination treatment, 41 of whom responded to monotherapy but did not achieve remission and 71 of whom did not respond to monotherapy.

The investigators found that patients who responded to monotherapy but did not achieve remission had significantly higher remission rates after subsequent combination therapy than the rates of those who did not respond to monotherapy (61% vs. 41%).

In addition, participants who responded to monotherapy but did not achieve remission had higher remission rates in the CBT plus medication group than in the medication plus CBT group (89% vs. 53%). However, analysis revealed that rates of response and remission were similar among patients whose depression did not respond to monotherapy regardless of what treatment group they were in.

Dunlop and colleagues also found that in both treatment groups, greater levels of anxiety — both before monotherapy as well as before initiating combination treatment — predicted poorer outcomes.

“Taken together, the existing data support the rationale for combining treatments with differing mechanisms of action, and differing efficacy as indicated by patients’ brain activity patterns to optimize treatment outcomes,” they wrote. “The sequential combination of CBT or antidepressant medication for patients who do not achieve remission with monotherapy is an effective approach for outpatients with major depression, and the sequence in which the treatments are applied does not appear to affect end-of-treatment outcomes.” – by Savannah Demko

Disclosures: Dunlop reports support from Acadia, Assurex Health, Axsome, Intra-Cellular Therapies, Janssen, NIMH, Otsuka, Pfizer, and Takeda. He also reports consulting for Assurex Health and Aptinyx. Please see the study for all other authors’ relevant financial disclosures.