Antidepressant medication or psychotherapy may be effective in treating chronically depressed patients when the other is not

Switching from an antidepressant medication to psychotherapy or vice versa may improve symptoms in chronically depressed patients who prove unresponsive to their initial treatment, according to an article in the May issue of Archives of General Psychiatry, one of the JAMA/Archives journals.

"A substantial proportion of patients treated for depression do not respond to the initial trial of either an antidepressant medication or depression-targeted psychotherapy," according to background information in the article. For those resistant to treatment there are several options available, including switching medication, enhancing or combining medications, and switching to or enhancing treatment with psychotherapy.

Alan F. Schatzberg, M.D., from Stanford University School of Medicine, Stanford, Calif., and colleagues studied chronically depressed patients who were treated with either nefazodone (an antidepressant medication) or cognitive behavioral analysis system of psychotherapy (CBASP) for 12 weeks. Participants in the nefazodone group received an initial does of 200 mg per day (100 mg twice daily), which increased to a maximum of 600 mg per day. Those in the CBASP group attended sessions twice weekly during the first four weeks and then once weekly until week 12. If unresponsive to either the nefazodone or CBASP, patients were switched to the other treatment.

Of the 156 nonresponders, 140 (89.7 percent) agreed to the crossover therapy. Both the switch from nefazodone to CBASP, and CBASP to nefazodone resulted in an improvement of depression symptoms. The response rates were 57 percent for those who crossed over from nefazodone to CBASP, and 42 percent for those who switched from CBASP to nefazodone. Remission rates were not significantly different in the two groups.

"Among chronically depressed individuals, CBASP appears to be efficacious for nonresponders to nefazodone, and nefazodone appears to be effective for CBASP nonresponders," the authors write. "For patients with chronic depression, the present results provide a strong basis for switching to CBASP after a medication does not produce a response and, conversely, for switching to medication after patients do not respond to an adequate trial of psychotherapy."

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