Efficacy of Pharmacotherapy and Cognitive Therapy, Alone and in Combination in Major Depressive Disorder

Article excerpt

Abstract

Objective: To assess the efficacy of pharmacotherapy (citalopram) and cognitive therapy alone, or in combination for the treatment of major depressive disorder.

Participants and Methods: This study was a randomised controlled clinical trial. In all, 120 adults with a major depressive disorder were assigned to an 8-week treatment with either citalopram, cognitive therapy, or both. Major depressive disorder was diagnosed using DSM-IV criteria. Patients were assessed with the Beck Depression Inventory before and after treatment.

Results: Statistical analysis showed that cognitive therapy, pharmacotherapy, and combined therapy were effective in the treatment of depression. There was no significant difference between the effects of medication and cognitive therapy. Combined treatment with the cognitive therapy and citalopram yielded better responses than treatment with citalopram or cognitive therapy alone.

Conclusion: Although antidepressant treatment or cognitive therapy effectively reduces the clinical symptoms and functional impairment associated with major depressive disorder, combination treatment is more efficacious.

Key words: Pharmacotherapy; Cognitive therapy; Depressive disorder

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Introduction

Antidepressant medications (ADMs) are the most widely used treatments for major depressive disorder. (1) Evidence from randomised placebo-controlled trials has supported their efficacy, particularly for more severely depressed patients. (2) Cognitive therapy pioneered by Beck et al has also shown promise in the treatment of major depressive disorder. (3,4) In a randomised, comparative trial, Rush et al (5) reported that cognitive therapy was more effective than ADM. However, their ADM dosages were low and the medications were tapered 2 weeks before final outcome assessment. Despite these shortcomings, their findings generated enthusiasm for cognitive therapy as an alternative to ADM for the treatment of depression.

Discussion of the comparative efficacy of ADM and cognitive behaviour therapy for the treatment of severely depressed patients has been marked by controversy. Findings from early comparative studies led many to conclude that cognitive behaviour therapy is at least as effective as ADM for the acute treatment for depression. (5-8) However, other reports suggested that it is not an effective treatment for severely depressed patients. (9-13) Findings from yet other randomised trials of ADM and cognitive behaviour therapy also need to be considered. Using criteria and measures employed by Elkin et al, (9) Hollon et al (14) found a very small advantage for cognitive behaviour therapy in their more severely depressed subgroup. This finding was at odds with the Treatment of Depression Collaborative Research Program, in which ADM outperformed cognitive behaviour therapy among the more severely depressed patients. (15) To examine the effects of both pharmacotherapy and cognitive therapy, we conducted a clinical trial comparing the 3-month efficacy of cognitive therapy and pharmacotherapy with that of combined therapy in patients with major depressive disorder of mild or moderate severity, defined according to DSM-IV criteria. (16)

Methods

Study Sample

The study sample consisted of consecutive new patients referred to 2 outpatient clinics of the Farshchian psychiatric centre in Hamadan, Iran. Farshchian psychiatric centre is a large psychiatric facility with several inpatient and outpatient clinics, covering a third of the population of Hamadan city. A total of 204 patients were screened. Of the 84 who did not undergo randomisation, 36 did not meet the study entry criteria (given below), 19 withdrew their consent, and 29 were excluded for other reasons (failure to return for further evaluation or non-compliance). One hundred and twenty patients underwent randomisation--40 were assigned to receive citalopram, 40 received cognitive therapy, and 40 received combined treatment. …