Academic journal article Journal of Evidence-Based Psychotherapies

The Combination of Psychotherapy and Pharmacotherapy in the Treatment of Adult Depression: A Comprehensive Meta-Analysis

Academic journal article Journal of Evidence-Based Psychotherapies

The Combination of Psychotherapy and Pharmacotherapy in the Treatment of Adult Depression: A Comprehensive Meta-Analysis

Article excerpt

Introduction

It is well-established that psychological and pharmacological therapies are effective in the treatment of adult depression. Several types of psychotherapy have been shown to be effective, including cognitive behavior therapy (Gloaguen, Cottraux, Cucherat, & Blackburn, 1998; Cuijpers, Berking, Andersson, Quigley, Kleiboer, & Dobson, 2013), interpersonal psychotherapy (Cuijpers, Geraedts, van Oppen, Andersson, Markowitz, & van Straten, 2011), behavioral activation therapy (Ekers, Richards, & Gilbody, 2008), problem-solving therapy (Malouff, Thorsteinsson, & Schutte, 2007), counseling (Cuijpers, Driessen, Hollon, van Oppen, Barth, & Andersson, 2012), and possibly psychodynamic therapy (Shedler, 2010). Dozens of trials directly comparing different types of psychotherapy have also shown that there are no or only small differences between the effects of these therapies and that all therapies seem to be about equally effective. In addition, guided self-help treatments including internet-based treatment (Cuijpers, Donker, van Straten, & Andersson, 2010; Andersson, & Cuijpers, 2009) and group treatments (Cuijpers, van Straten, & Warmerdam, 2008) appear to be as effective as face-to-face treatments with one therapist and one patient. Several types of antidepressant medications have also been found to be effective, including tricyclic antidepressants, SSRIs and several others (Bauer, Pfennig, Severus, Whybrow, Angst, Möller, et al., 2013). Several hundreds of trials directly comparing different types of medication have also shown that all these medications are most likely about equally effective (Gartlehner, Hansen, Morgan, Thaler, Lux, Van Noord, et al., 2012). In addition, dozens of direct comparisons between psychotherapies and pharmacotherapies have shown that psychotherapies and pharmacotherapies are also equally effective or approximately equally effective (Cuijpers, Sijbrandij, Koole, Andersson, Beekman, & Reynolds, 2013). This suggests that all psychological and pharmacological treatments of adult depression are equally effective or about equally effective for mild to moderate depression, although this may not pertains to more chronic forms of depression and dysthymia (Cuijpers, van Straten, Schuurmans, van Oppen, Hollon, & Andersson, 2010).

The combination of psychotherapy and pharmacotherapy, however, has been shown to be more effective then pharmacotherapy alone (de Maat, Dekker, Schoevers, & de Jonghe, 2007; Cuijpers et al., 2014), psychotherapy alone (Pampallona, Bollini, Tibaldi, Kupelnick, & Munizza, 2004), and the combination of psychotherapy and placebo (Cuijpers, Turner, Mohr, Hofmann, Andersson, Berking, et al., 2011). Combined treatment seems to be, therefore, the most effective treatment currently available for adult depression.

The mechanisms behind the added effect of combining treatments is largely unknown. One possible mechanism would be that different patients respond to different treatments and hence providing two treatments would result in more patients improving. However, it is also possible that the two treatment formats (for simplicity we here assume that pharmacotherapy and psychotherapy are two separate forms of treatments bearing in mind that there are different forms of both pharmacotherapy and psychotherapy) interact. An example of this could be if a patient gets initial help from the psychotherapy, then additional boost from medication, and then additional help from the skills and insights gained in psychotherapy. However, placebo effects appear to ubiquous in depression treatments in particular when there is contact with the study coordinators (Posternak & Zimmerman, 2007), and hence there is a need to elucidate how well combined treatment works against placebo only and indeed also single treatments.

No meta-analysis has examined the effects of combined treatment against pill placebo only. As mentioned earlier, there have been meta-analyses in which combined treatment was compared with pharmacotherapy alone and with psychotherapy alone (De Maat et al. …

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