Combining psychotherapy and pharmacotherapy

Meet the patient

A 48-year-old teacher has been on sertraline for ten weeks. Her PHQ-9 has fallen from 19 to 11 — better, but not well. She still wakes at 5am, ruminates on the lesson she "ruined" in March, and has stopped seeing friends. Her GP added mirtazapine last month because "the sertraline wasn't working." She asks you, plainly: "Do I need more tablets, or do I need to talk to someone?"^[1][13]

Every examiner wants the same answer from you: is this a drug problem or a therapy problem — and how do you decide? The fellowship answer is that it is neither alone, and the decision runs through adequacy, residual symptoms, and the sequential model.^[3][15]

References20ShowHide

1. [1]Keller MB, McCullough JP, Klein DN, et al. A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression N Engl J Med, 2000.PMID 10816183
2. [2]Schatzberg AF, Rush AJ, Arnow BA, et al. Chronic depression: medication (nefazodone) or psychotherapy (CBASP) is effective when the other is not Arch Gen Psychiatry, 2005.PMID 15867104
3. [3]Cuijpers P, Sijbrandij M, Koole SL, et al. Adding psychotherapy to antidepressant medication in depression and anxiety disorders: a meta-analysis World Psychiatry, 2014.PMID 24497254
4. [4]Cuijpers P, Noma H, Karyotaki E, et al. A network meta-analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression World Psychiatry, 2020.PMID 31922679
5. [5]Cuijpers P, Miguel C, Harrer M, et al. Cognitive behavior therapy vs. control conditions, other psychotherapies, pharmacotherapies and combined treatment for depression: a comprehensive meta-analysis including 409 trials with 52,702 patients World Psychiatry, 2023.PMID 36640411
6. [6]Cuijpers P, Sijbrandij M, Koole SL, et al. The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: a meta-analysis of direct comparisons World Psychiatry, 2013.PMID 23737423
7. [7]Pampallona S, Bollini P, Tibaldi G, et al. Combined pharmacotherapy and psychological treatment for depression: a systematic review Arch Gen Psychiatry, 2004.PMID 15237083
8. [8]DeRubeis RJ, Hollon SD, Amsterdam JD, et al. Cognitive therapy vs medications in the treatment of moderate to severe depression Arch Gen Psychiatry, 2005.PMID 15809408
9. [9]Hollon SD, DeRubeis RJ, Shelton RC, et al. Prevention of relapse following cognitive therapy vs medications in moderate to severe depression Arch Gen Psychiatry, 2005.PMID 15809409
10. [10]March J, Silva S, Petrycki S, et al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial JAMA, 2004.PMID 15315995
11. [11]Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety N Engl J Med, 2008.PMID 18974308
12. [12]Pediatric OCD Treatment Study (POTS) Team Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial JAMA, 2004.PMID 15507582
13. [13]Wiles N, Thomas L, Abel A, et al. Cognitive behavioural therapy as an adjunct to pharmacotherapy for primary care based patients with treatment resistant depression: results of the CoBalT randomised controlled trial Lancet, 2013.PMID 23219570
14. [14]Miklowitz DJ, Otto MW, Frank E, et al. Psychosocial treatments for bipolar depression: a 1-year randomized trial from the Systematic Treatment Enhancement Program Arch Gen Psychiatry, 2007.PMID 17404119
15. [15]Guidi J, Fava GA Sequential Combination of Pharmacotherapy and Psychotherapy in Major Depressive Disorder: A Systematic Review and Meta-analysis JAMA Psychiatry, 2021.PMID 33237285
16. [16]Frank E, Kupfer DJ, Perel JM, et al. Three-year outcomes for maintenance therapies in recurrent depression Arch Gen Psychiatry, 1990.PMID 2244793
17. [17]Wykes T, Steel C, Everitt B, Tarrier N Cognitive behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigor Schizophr Bull, 2008.PMID 17962231
18. [18]Kamenov K, Twomey C, Cabello M, et al. The efficacy of psychotherapy, pharmacotherapy and their combination on functioning and quality of life in depression: a meta-analysis Psychol Med, 2017.PMID 27780478
19. [19]Hofmann SG, Sawyer AT, Korte KJ, Smits JA Is it Beneficial to Add Pharmacotherapy to Cognitive-Behavioral Therapy when Treating Anxiety Disorders? A Meta-Analytic Review Int J Cogn Ther, 2009.PMID 19714228
20. [20]Fava GA, Tomba E New modalities of assessment and treatment planning in depression: the sequential approach CNS Drugs, 2010.PMID 20443645