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Severely Depressed Most Responsive to Combined Cognitive and Drug Rx

Severely Depressed Most Responsive to Combined Cognitive and Drug Rx

A large-scale clinical trial examined outcomes from acute through continuation treatment of depression.1 Patients with severe, nonchronic MDD were more likely to have symptom remission with a combination of cognitive therapy and antidepressant medication than those with less severe or more chronic illness.

Lead author Steven Hollon, PhD, Department of Psychology, Vanderbilt University, told Psychiatric Times that the combination of cognitive therapy with medications had a big effect for patients with severe, nonchronic depression “but was not needed by patients with less severe, nonchronic depression [as] they did well regardless, and did not help patients with chronic depression regardless of severity [as] they did less well regardless.”

Hollon and colleagues recruited 452 patients with chronic or recurrent MDD from 3 university-affiliated outpatient clinics. Participants were randomized to receive personalized antidepressant medication treatment with or without a standardized cognitive therapy. The depressive illness was categorized as chronic if episodes lasted 2 years or longer, or recurrent if an episode had followed another within the past 3 years.

Treatment of both groups continued for up to 19 months to attain remission and for up to 42 months to achieve recovery (defined as remission sustained for 26 consecutive weeks). Changes in depression symptoms were assessed at intervals throughout the study with the 17-item Hamilton Rating Scale for Depression and the Longitudinal Interval Follow-up Evaluation.

Antidepressant medication treatment was personalized for all patients, consistent with best clinical practices. Dosages were increased as rapidly as possible and maintained at maximum tolerated levels for at least 4 weeks. The antidepressant could be switched and/or augmented with adjunctive agents. The Beck model of cognitive therapy was applied following standardized protocol, with 50-minute sessions provided twice weekly for at least 2 weeks, then at least weekly through acute treatment and at least monthly during continuation, with the frequency adjusted to patient needs.

Patients who had severe but nonchronic depression at study entry and received the combination therapy had a better rate of recovery than those who received medication alone (81.3% vs 51.7%). The median recovery rates across all groups who received combination therapy were better than for those who received medication without cognitive therapy (72.6% vs 62.5%). Remission rates were high but were not statistically signficantly different between groups, occurring in 63.6% of patients who received combination treatment and 60.3% with medication. Although median time to remission was shorter with the combination treatment, that difference was also not statistically significant.

“The study shows that different people respond to different treatment combinations,” Hollon remarked. “We clearly need to do more for the patients with chronic depression.”

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