Researchers examined data from 17 randomized clinical trials that, combined, had a total of 1,208 patients with major depressive disorder who received sequential treatment with pharmacotherapy followed by psychotherapy, and 1,075 in control arms that didn't receive this intervention. The pooled risk ratio for recurrence or relapse was lower with sequential therapy (0.84).
"The rationale of the sequential model in depression is to provide psychotherapy after successful response to acute-phase antidepressant medication to improve symptoms that pharmacotherapy was unable to affect, since these treatments have specific, different therapeutic targets," said study co-author Jenny Guidi, a psychology researcher at the University of Bologna in Italy.
"Psychotherapeutic strategies are thus employed when they are most likely to make a unique and separate contribution to patients' well-being," Guidi said by email.
The preventive value of the sequential integration of psychotherapy after pharmacotherapy mostly relies on the abatement of residual symptoms that tend to persist and negatively affect the longitudinal course of depressive disorders, as well as restoration or enhancement of psychological well-being, Guidi added.
Participants' mean age was 45.9 years and 69.2% were female.
Each of the smaller studies in the analysis examined some form of cognitive behavioral therapy; twelve studies delivered psychotherapy in group sessions and five used individual sessions.
When researchers looked at outcomes from sequential integration of psychotherapy after acute pharmacotherapy, they didn't find a significant difference in outcomes based on whether patients continued medication or tapered off medicines during psychotherapy.
The pooled risk ratio for sequential psychotherapy with continued antidepressant medication was 0.82, compared with a pooled risk ratio with discontinuation of antidepressants of 0.86. This difference wasn't statistically significant.
These results suggest that maintenance or discontinuation of antidepressants should be based on clinical judgement, and made on a case-by-case basis, Guidi said.
"The sequential model introduces a conceptual shift in clinical practice, since it requires a substantially different approach encompassing a longitudinal view of the depressive illness staging, clinical reasoning and case conceptualization based on macro-analysis, repeated assessments over time, and administration of therapeutic ingredients for as long as they are needed," Guidi added.
One limitation of the meta-analysis is that the included studies varied widely in design and methods for measuring outcomes, the study team notes in JAMA Psychiatry. Exclusion criteria may also limit the generalizability of the results.
Even so, the results should give clinicians increased confidence that adding a cognitive behavioral therapy-based psychotherapy after patients have had a good but incomplete response to antidepressant treatment is a good approach for reducing the likelihood of a future depressive relapse, said Dr. Boadie Dunlop, a professor and director of the Mood and Anxiety Disorders Program at Emory University School of Medicine in Atlanta.
"This is consistent with other work suggesting that even after a poor response to a trial of treatment with an antidepressant, treatment with an evidence-based psychotherapy either alone or in combination with an antidepressant should be strongly considered," Dr. Dunlop, who wasn't involved in the study, said by email.
SOURCE: https://bit.ly/2VARH0O JAMA Psychiatry, online November 25, 2020.
By Lisa Rapaport
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