In Brief

Mental health researchers are calling for further investigation of whether the combination of medication and structured psychotherapy more effectively combats chronic depression than either treatment alone, as found in a recent, much publicized study.

The study, published in the New England Journal of Medicine (Vol. 342, No. 20), is the first large-scale study to suggest that a blend of psychotherapy and medication is superior to other treatments for depression, says APA Past President Martin E.P. Seligman, PhD, of the University of Pennsylvania.

"The new finding is surprising in light of the repeated failures to find additivity of cognitive behavioral therapy and medication for episodes of unipolar depression," he says. "It stands in need of independent replication."

Accounting for why the combination proved so powerful in this research may be the type of depression studied--the chronic form--and the kinds of treatment used, says Virginia Commonwealth University psychologist James McCullough, PhD. An author on the study, McCullough developed the cognitive behavioral analysis system (CBAS) of psychotherapy used with its participants. The system seeks to counteract chronic depression by emphasizing empathy, social problem-solving and efficacy in interpersonal relations.

Meanwhile, the drug used, nefazodone (Serzone), is a relatively new antidepressant that eases insomnia, promotes concentration and produces fewer side effects than many other antidepressants. In the study, involving 681 patients at 12 outpatient psychiatric clinics and academic medical centers nationwide, a third of patients received the drug, a third received CBAS therapy and the rest received a combination for 12 weeks. Among all patients, dropouts included, the combination produced a 73 percent response rate--defined as an improvement of 50 percent in scores on the Hamilton Rating Scale for Depression. By comparison, each treatment in isolation garnered a 48 percent response rate.

Even more remarkable, when dropouts were factored out, the blend of treatments produced an 85 percent response rate, compared with one of 55 percent for nefazodone alone and 52 percent for psychotherapy alone. Nefazodone showed the most immediate effects on patients, rendering improvements by week four, then leveling off. Psychotherapy showed more gradual improvement. But when used with the drug, psychotherapy appeared to bolster its affects from week six onward.

"The results suggest that, with this patient population at least, we ought to use a combination treatment," says McCullough. "It seems that giving people a boost with meds enables them to focus, to concentrate on the psychotherapy and respondto it."

But McCullough cautions that the study's findings do not generalize to other forms of depression, psychotherapy and medication. They also have yet to be replicated, as noted by Seligman. What's more, the study was subsidized by Bristol-Myers Squibb Co., which manufactures the drug used. McCullough looks to the National Institute of Mental Health for further, independent trials exploring combination treatments.