Antidepressants are the first-choice treatment for severe depression. The use of antidepressants is often supplemented with psychotherapy. Now, a large ongoing international study has shown that adding psychotherapeutic treatment to antidepressants does not improve treatment outcomes in severely depressed patients. The study, presented at the European Congress of Psychiatry*, also found that patients with severe depression who were also treated with additional psychotherapy tended to be younger, more often employed, better educated and to have less initial depression. severe than those treated exclusively with antidepressants.
Rates of clinical depression have doubled over the past 30 years, with the WHO estimating that around 322 million people worldwide suffer from it. This is roughly equivalent to the total populations of Germany, France, Spain, Italy and the United Kingdom combined. About a third of people with severe depression do not respond well to treatment; they are “treatment resistant,” meaning that clinicians should look for ways to improve current treatments.
The new study in European patients with major depression (clinically called Major depressive disorder, MDD) treated under real-life conditions found that approximately 1 in 3 patients treated with antidepressants also receive psychotherapy – a non-pharmacological treatment, where patients discuss their condition with a physician or trained therapist. About ¾ of these patients treated with both antidepressants and psychotherapy received cognitive behavioral therapy.
Clinicians from European Group for the Study of Resistant Depression, based in Austria, Italy, Belgium, Germany, Greece, France, Israel and Switzerland, studied the effects of a combination treatment in 1279 severely depressed adult patients. These patients had been appropriately treated with antidepressant medications. 31.2% of them had undergone additional psychotherapy. People receiving additional psychotherapy tended to be younger, better educated, more often employed, and with a lower risk of suicide than those treated exclusively with antidepressants. Additionally, they experienced an earlier onset of severe depression, more migraines and asthma, and received lower daily doses of antidepressants than those treated exclusively with antidepressants. The severity of depression in each patient was measured using the Hamilton Depression Rating Scale and the Montgomery and Åsberg Depression Rating Scale. The researchers found that using additional psychotherapy did not lead to better treatment outcomes.
Lead researcher Prof. Siegfried Kasper MD (Medical University of Vienna) said:
“There are two main points that emerge from our work. First, if you have been treated with antidepressants, additional psychotherapy does not seem to give you better treatment outcomes, although it may improve your subjective well-being. The second point is that patients with severe depression who received complementary psychotherapy had more favorable sociodemographic and clinical characteristics than those who did not receive complementary psychotherapy.
Our data show that supplemental psychotherapy tends to be given to more educated and healthier patients, which may reflect the greater availability of psychotherapy for more socially and economically advantaged patients..
Presenting the work at the European Congress of Psychiatry (EPA’s virtual congress), researcher Dr Lucie Bartova (Medical University of Vienna) said:
“Given these results and existing clinical guidelines, we recommend that clinicians and patients follow the recommended treatment pathways to ensure the best care for them. If people have any doubts about the treatment, they should consult their psychiatrist to agree on the course of action”.
In follow-up work, 292 depressed patients receiving cognitive behavioral therapy, which is the recommended psychotherapeutic strategy in severe depression, were compared with 107 patients treated with other psychotherapeutic techniques such as psychoanalytic psychotherapy or systemic psychotherapy. The researchers found that there was no difference in treatment outcomes.
Commenting, Dr Livia De Picker (University of Antwerp) said:
“Despite clinical guidelines and studies that advocate psychotherapy and combine psychotherapy with antidepressants, this study shows that in real life no added value can be demonstrated for psychotherapy in people already treated with antidepressants for severe depression. This does not necessarily mean that psychotherapy is not helpful, but it is a clear sign that the way we currently manage these depressed patients with psychotherapy is not effective and needs critical evaluation..”
This is an independent comment; Dr. De Picker was not involved in this work.
*Some of this work is being presented at the conference for the first time, but the majority of this work has been published in the peer-reviewed journal Psychiatric Research Journal (“The combination of psychopharmacotherapy and psychotherapy is not associated with better treatment outcomes in major depressive disorder – evidence from the European Group for the Study of Resistant Depression», Bartova et al. See https://tinyurl.com/y5td8yjj).
The authors note that the study was designed to look at treatment-resistant depression, so these findings are secondary results. They have taken steps to allow this.
Conflict of Interest Statement
You’re welcome. Funding: The Group for the Study of Resistant Depression (GSRD) received an unrestricted grant sponsored by Lundbeck A/S. The sponsor had no role in the study design, data collection, data analysis, data interpretation, report writing, and decision to submit the study for publication.
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