MEQ: Designing combined treatment for chronic depression with partial SSRI response

(i) Models and fit (5). Concurrent combination: structured psychotherapy and pharmacotherapy delivered in the same acute/continuation phase. Sequential combination: one modality first (often medication to response), then psychotherapy for residual symptoms, well-being, and relapse prevention (or reverse sequences in some designs). Stepped care escalates intensity with non-response. This man has chronic illness with partial medication response and residual behavioural/interpersonal maintaining factors — concurrent adjunctive structured therapy on continued antidepressant is appropriate now; if he reaches fuller response later, sequential residual-focused work remains relevant. False dichotomy of stop meds or start therapy is not required.^[1][4]

(ii) Evidence (5). Chronic depression: Keller NEJM — nefazodone + CBASP combination superior to either monotherapy at 12 weeks (design lesson survives nefazodone’s historical status).^[1] Adding psychotherapy to antidepressants improves outcomes versus medication alone (Cuijpers 2014); network meta-analysis finds combination superior to either monotherapy in adult depression (Cuijpers 2020).^[2][5] CoBalT: CBT adjunctive to usual care including antidepressants helps treatment-resistant primary-care depression.^[3] Guidi–Fava: sequential psychotherapy after pharmacologic response targets residual symptoms and recurrence.^[4] Prior three unstructured sessions without homework do not constitute an adequate CBT trial.

(iii) Practical plan (5). Medication: continue sertraline 150 mg oral daily if tolerated; optimise adherence/side effects; if still partial after adequate duration, consider guideline-supported next steps later — do not abandon the current agent solely to “make room for therapy.” Therapy: high-fidelity CBT with behavioural activation for morning inactivity, cognitive work on failure schema, interpersonal problem-solving for work conflict; or CBASP-informed interpersonal focus given chronicity. Session structure: agenda, homework, measures (PHQ-9). Shared goals written. If split care: letter/call between psychiatrist and therapist covering diagnosis, risk, regimen, and therapy targets. Review 4–6 weeks with scores and homework fidelity.^[2][3]

(iv) Pitfalls (5). False dichotomy tablets vs talking; pseudo-CBT without techniques; premature polypharmacy without offering real therapy; ignoring residual symptoms after partial score drop; missing evolving suicide risk when shame spikes; cultural meanings of medication; no communication in split care. Acute risk escalation overrides elective session structure.^[3][4]