It was just over a generation ago that the routine combination of psychotherapy and drug therapy seemed impossible. Especially in America, psychiatry was polarized by ideologic and political struggles between psychoanalysis and biologic psychiatry. American psychoanalysts tended to regard psychopharmacology as an inferior treatment that covered over problems rather than addressing them. They assumed that symptoms suppressed by drugs would eventually be replaced by others equally disabling. In turn, proponents of biologic psychiatry often viewed psychoanalysis as a form of quackery that was, at best, a costly waste of time, and, at worst, heightened distress that the psychopharmacologist was trying to ameliorate.
Benefits of combined treatment
In the 1970s, a number of influential studies cut through ideologic assumptions and began to reshape the way we viewed the practice of combining therapy and medications. Klerman and coworkers1 tested the assumption that psychotherapy and psychopharmacology were essentially in conflict, each undermining the work of the other. There was no evidence that psychopharmacologic treatment led to therapy discontinuation or to symptom substitution or that psychotherapy exacerbated patients' distress. Then, Luborsky and colleagues,2 in a meta-analysis comparing the effectiveness of different psychodynamic psychotherapies, made an interesting discovery. All therapies were equally effective, with one notable exception: combined treatment with psychotherapy and medication was found to be notably superior to either treatment alone.
Since then, numerous studies have shown combined treatment for depression to have many benefits over single-modality treatment (Table 1). This applies not only to psychodynamic therapy, but also to interpersonal therapy (IPT), a manualized descendent of psychodynamic psychotherapy.3 The evidence was less clear for cognitive-behavioral therapies (CBT), with several early studies showing only nonsignificant trends toward a benefit of combined treat- ment.4 It appears, however, that this may reflect limitations in study design typical of that period.5 Other studies showed a benefit to combining CBT and pharmacotherapy.6-8
Empirically validated benefits of combined treatment
|Improved short-term recovery rates||Multiple studies|
|Faster responses||Bowers, 19908|
|Improved long-term recovery rates||Fava et al, 199833|
|Decreased rate of relapse||Paykel et al, 199918;
Teasdale et al, 200019
|Improved long-term social functioning||Klerman et al, 19741|
|Improved medication compliance||Basco and Rush, 199524;
de Jonghe et al, 200125; Vergouwen et al, 200326
|Greater patient satisfaction||Seligman, 199528;
de Jonghe et al, 200125
|Lower long-term health and social service costs||Browne et al, 200234,
Goldman et al, 199832
Does this mean that all patients presenting with depression should be offered treatment with a combination of psychotherapy and medications? In an ideal world with unlimited resources, this might be the case. However, there is the cost/benefit ratio to consider. Though combined treatment is more effective than single-modality treatment, the effect sizes are generally modest.9 Differences that are statistically significant may not be clinically significant. Given the added strain of providing combined treatment on limited mental health services, it would be far better selectively to provide combined treatment to those patients most likely to show a significant benefit.
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