Adding psychotherapy to pharmacologic treatment does not appear to improve treatment outcomes for patients with major depression, new research suggests.
Results of a cross-sectional, naturalistic, multicenter European study showed there were no significant differences in response rates between patients with major depressive disorder (MDD) who received combination treatment with psychotherapy and antidepressant medication in comparison with those who received antidepressant monotherapy, even when comparing different types of psychotherapy.
This “might emphasizes the fundamental role of the underlying complex biological interrelationships in MDD and its treatment,” said study investigator Lucie Bartova, MD, PhD, Clinical Division of General Psychiatry, Medical University of Vienna, Austria.
However, she noted that patients who received psychotherapy in combination with antidepressants also had “beneficial sociodemographic and clinical characteristics,” which might reflect poorer access to “psychotherapeutic techniques for patients who are more severely ill and have less socioeconomic privilege.”
The resulting selection bias may cause patients with more severe illness to “fall by the wayside,” Bartova said.
Lead researcher Siegfried Kasper, MD, also from the Medical University of Vienna, agreed, saying in a release that, by implication, “additional psychotherapy tends to be given to more highly educated and healthier patients, which may reflect the greater availability of psychotherapy to more socially and economically advantaged patients.”
The findings, some of which were previously published in the Journal of Psychiatry Researchwere presented at the virtual European Psychiatric Association (EPA) 2022 Congress.
During her presentation, Bartova said that while “numerous effective antidepressant strategies are available for the treatment of MDD, many patients do not achieve a satisfactory treatment response,” which often leads to further management refinement and the use of off-label treatments.
She continued, saying that the “most obvious” approach in these situations is to try the available treatment options in a “systematic and individualized” manner, ideally by following recommended treatment algorithms.
Meta-analyses have suggested that standardized psychotherapy with fixed, regular sessions that follows an established rationale and is based on a defined school of thought is effective in MDD, “with at least moderate effects.”
Among the psychotherapy approaches, cognitive-behavioral therapy (CBT) is the “best and most investigated,” Bartova said, but international clinical practice guidelines “lack consistency” regarding recommendations for psychotherapy.
To examine the use and impact of psychotherapy for MDD patients, the researchers studied 1410 adult inpatients and outpatients from 10 centers in eight countries who were surveyed between 2011 and 2016 by the European Group for the Study of Resistant Depression.
Participants were assessed using the Mini–International Neuropsychiatric Interview, the Montgomery-Åsberg Depression Rating Scale, and the Hamilton Depression Rating Scale.
Results showed that among 1279 MDD patients who were included in the final analysis, 68.8% received only antidepressants, while 399 (31.2%) received some form of structured psychotherapy as part of their treatment.
These patients included 22.8% who received CBT, 3.4% who underwent psychoanalytic psychotherapy, and 1.3% who received systemic psychotherapy. The additional psychotherapy was not specified for 3.8%.
Bartova explained that the use of psychotherapy in combination pharmacologic treatment was significantly associated with younger age, higher educational attainment, and ongoing employment in comparison with antidepressant use alone (P < .001 for all).
In addition, combination therapy was associated with an earlier average age of MDD onset, lower intensity of current depressive symptoms, a lower risk of suicidality, higher rates of additional melancholic features in the patients’ symptomatology, and higher rates of comorbid asthma and migraine (P < .001 for all).
There was also a significant association between the use of psychotherapy plus pharmacologic treatment and lower average daily doses of first-line antidepressant medication (P < .001), as well as more frequent administration of agomelatine (P < .001) and a trend toward greater use of vortioxetineP = .006).
In contrast, among patients who received antidepressants alone, there was a trend toward higher rates of additional psychotic features (P = .054), and the patients were more likely to have received selective serotonin reuptake inhibitors as their first-line antidepressant medication (P < .001).
The researchers found there was no significant difference in rates of response, nonresponse, and treatment-resistant depression (TRD) between patients who received combination psychotherapy and pharmacotherapy and those who received antidepressants alone (P = .369).
Bartova showed that 25.8% of MDD patients who received combination therapy were classified as responders, compared with 23.5% of those given only antidepressants. Nonresponse was identified in 35.6% and 33.8% of patients, respectively, while 38.6% vs 42.7% had TRD.
Bartova and colleagues performed an additional analysis to determine whether there was any difference in response depending on the type of psychotherapy.
They divided patients who received combination therapy into those who had received CBT and those who had been given another form of psychotherapy.
Again, there were no significant differences in response, nonresponse, and TRD (P = .256). The response rate was 27.1% among patients given combination CBT, vs 22.4% among those who received another psychotherapy.
“Despite clinical guidelines and studies which advocate for psychotherapy and combining psychotherapy with antidepressants, this study shows that in real life, no added value can be demonstrated for psychotherapy in those already treated with antidepressants for severe depression,” said Livia De Picker, MD, PhD, Collaborative Antwerp Psychiatric Research Institute, University of Antwerp, in Belgium, in the release.
“This doesn’t necessarily mean that psychotherapy is not useful, but it is a clear sign that the way we are currently managing these depressed patients with psychotherapy is not effective and needs critical evaluation,” added De Picker, who was not involved in the research.
However, Michael Edward Thase, MD, professor of psychiatry, University of Pennsylvania, in Philadelphia, told Medscape Medical News that the current study “is a secondary analysis of a naturalistic study.”
Accordingly, it is not possible to account for the “dose and duration, and quality, of the psychotherapy provided.”
Therefore, the findings simply suggest that “the kinds of psychotherapy provided to these patients were not so powerful that people who received it consistently did better than those who did not,” Thase said.
The European Group for the Study of Resistant Depression obtained an unrestricted grant sponsored by Lundbeck A/S. Bartova has relationships with AOP Orphan, Medizin Medien Austria, Universimed, Vertretungsnetz, Dialectica, Diagnosia, Schwabe, Janssen, Lundbeck, and Agenlini. No other relevant financial relationships have been disclosed.
European Psychiatric Association (EPA) 2022 Congress: Abstract Psychotherapy Employed Additionally to Psychopharmacotherapy Is Not Related to Better Treatment Outcome in Major Depressive Disorder. Presented June 5, 2022.
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