Combining psychotherapy with antidepressants does not improve outcomes in severely depressed patients

Antidepressants are the first-choice treatment for severe depression. Antidepressant use is often supplemented by psychotherapy. Now a major ongoing international study has shown that adding psychotherapy treatment to antidepressant medication does not improve treatment outcomes in severely depressed patients. The study, presented at the European Congress of Psychiatry, also found that those patients with severe depression who were also treated with additional psychotherapy tended to be younger, more often employed, more highly educated, and have less severe initial depression than those who were treated with antidepressant medication exclusively.

Rates of clinical depression have doubled in the last 30 years, with the WHO estimating that around 322 million people suffer worldwide. This is roughly equivalent to the total populations of Germany, France, Spain, Italy and the UK combined. Around a third of severe depression sufferers don't respond well to therapy; they are 'treatment resistant', meaning that clinicians need to look for ways to improve current treatments.

The new study performed in European patients with major depression (clinically known as Major Depressive Disorder, MDD) treated under real-world conditions has found that around 1 in 3 patients treated with antidepressant medication also receive psychotherapy – non-pharmacological treatment, where patients discuss their condition with a qualified doctor or therapist. Around ¾ of these patients treated with both, antidepressant medication and psychotherapy, underwent Cognitive Behavioral Therapy.

Clinicians from the European Group for the Study of Resistant Depression, based in Austria, Italy, Belgium, Germany, Greece, France, Israel, and Switzerland, studied the effects of combined treatment in 1279 severely depressed adult patients. These patients had been treated appropriately with antidepressant medication. 31.2% of those had gone on to receive additional psychotherapy. Those receiving additional psychotherapy tended to be younger, more highly educated, more often employed, and with a lower suicide risk than those treated exclusively with antidepressant medications. In addition, they experienced an earlier onset of severe depression, more migraines and asthma, and received lower daily doses of antidepressants than those treated exclusively with antidepressants. The severity of depression in each patient was measured using the Hamilton Rating Scale for Depression, and the Montgomery and Åsberg Depression Rating Scale. The researchers found that the use of additional psychotherapy did not lead to better treatment outcomes.

Lead researcher, Prof. Siegfried Kasper MD (Medical University of Vienna) said:

"There are two main points that comes out of our work. Firstly, if you have been treated with antidepressants, additional psychotherapy does not seem to give you better treatment outcomes, even though it may improve your subjective well-being. The second point is that those patients suffering from severe depression and receiving additional psychotherapy had more favorable socio-demographic and clinical characteristics than those who didn't receive additional psychotherapy.

Our data shows that 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".

Presenting the work at the European Congress of Psychiatry (EPA virtual congress), researcher Dr Lucie Bartova (Medical University of Vienna) said:

"Taking these results, and existing clinical guidelines, into account, we would recommend that clinicians and patients follow the recommended treatment paths to ensure the best care for them. If people have any doubts about treatment they should see their psychiatrist to agree how to move forward".

In follow-up work, 292 depressed patients receiving Cognitive Behavioural Therapy, which is the recommended psychotherapeutic strategy in severe depression, were compared to 107 patients treated with other psychotherapeutic techniques such as psychoanalytic psychotherapy or systemic psychotherapy. The researchers found that there was no difference in treatment outcome.

Commenting, Dr Livia De Picker (University of Antwerp) said:

"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. 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."

This is an independent comment; Dr De Picker was not involved in this work.