Background: Despite significant advances in therapy, approximately one half of chronically depressed patients do not respond to an adequate trial of appropriate medications. A common strategy is to add psychotherapy, but the effectiveness of adjunctive psychotherapy is poorly defined. Kocsis and colleagues studied the impact on response and remission rates resulting from the addition of the cognitive behavioral analysis system of psychotherapy or brief supportive psychotherapy to pharmacotherapy in patients with chronic depression.

The Study: At eight participating academic centers, patients were recruited if they met criteria for major depressive disorder for at least four weeks and reported depressive symptoms for more than two years without remission (double depression). Patients with psychosis, dementia, bipolar disorder, personality disorder, or posttraumatic stress disorder were excluded, as were those with serious or unstable medical conditions and those who had previously experienced the cognitive behavioral analysis system of psychotherapy. More than 800 patients began antidepressant therapy and subsequently were evaluated every two weeks for 12 weeks. Patients who did not achieve remission based on reductions in scores on the Hamilton Scale for Depression (HAM-D) alone or in conjunction with persistent symptoms were randomized to add either the cognitive behavioral analysis system of psychotherapy or brief supportive psychotherapy to their medication regimen or to continue pharmacotherapy alone.

Results: At 12 weeks, 491 patients met criteria for poor response to pharmacotherapy. After randomization, the two patient groups that received adjunctive psychotherapy had a slightly higher percentage of white participants, but the three study groups did not differ significantly in any other important variables. Patients assigned to brief supportive psychotherapy and the cognitive behavioral analysis system of psychotherapy attended a mean of 13.1 and 12.5 sessions, respectively. Patients in all three groups attended an average of five pharmacotherapy visits.

During the 12-week period, the mean HAM-D scores dropped in patients who initially had no response to antidepressants and in partial responders. Among patients who had adjunctive psychotherapy and those who continued on medication alone, there were no statistical differences in the percentage with full response (15.3 versus 14.7 percent, respectively), partial response (26.2 versus 21.3 percent, respectively), and no response (58.5 versus 64.0 percent, respectively). No statistical differences could be demonstrated between patients assigned to the brief supportive psychotherapy and the cognitive behavioral analysis system of psychotherapy groups in depression scores or rates of full or partial remission.

Conclusion: The authors report that about 38 percent of patients with chronic depression achieved partial or full remission during the second 12-week phase of treatment, but neither form of adjunctive psychotherapy provided notably better results than individualized pharmacotherapy.