Psychotherapy and Medication in the Treatment of Adult and Geriatric Depression: Which Monotherapy or Combined Treatment?

Steven D. Hollon, Ph.D.; Robin B. Jarrett, Ph.D.; Andrew A. Nierenberg, M.D.; Michael E. Thase, M.D.; Madhukar Trivedi, M.D.; and A. John Rush, M.D.

Objective: The authors reviewed the literature with respect to the relative efficacy of medications and psychotherapy alone and in combination in the treatment of depression.

Data Sources and Study Selection: Findings from empirical studies comparing medications and psychotherapy alone and in combination were synthesized and prognostic and prescriptive indices identified. We searched both MEDLINE and PsychINFO for items published from January 1980 to October 2004 using the following terms: treatment of depression, psychotherapy and depression, and pharmacotherapy and depression. Studies were selected that randomly assigned depressed patients to combined treatment versus monotherapy.

Data Synthesis: Medication typically has a rapid and robust effect and can prevent symptom return so long as it is continued or maintained, but does little to reduce risk once its use is terminated. Both interpersonal psychotherapy (IPT) and cognitive-behavioral therapy (CBT) can be as effective as medications in the acute treatment of depressed outpatients. Interpersonal psychotherapy may improve interpersonal functioning, whereas CBT appears to have an enduring effect that reduces subsequent risk following treatment termination. Ongoing treatment with either IPT or CBT appears to further reduce risk. Treatment with the combination of medication and IPT or CBT retains the specific benefits of each and may enhance the probability of response over either monotherapy, especially in chronic depressions.

Conclusion: Both medication and certain targeted psychotherapies appear to be effective in the treatment of depression. Although several prognostic indices have been identified that predict need for longer or more intensive treatment, few prescriptive indices have yet been established to select among the different treatments. Combined treatment can improve response with selected patients and enhance its breadth (IPT) or stability (CBT).

(J Clin Psychiatry 2005;66:455-468)

Received Jan. 30, 2004; accepted Dec. 2, 2004. From the Department of Psychology, Vanderbilt University, Nashville, Tenn. (Dr. Hollon); the Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas (Drs. Jarrett, Trivedi, and Rush); the Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston (Dr. Nierenberg); and the Department of Psychiatry, University of Pittsburgh Medical Center and Western Psychiatric Institute and Clinic, Pittsburgh, Pa. (Dr. Thase).

This work was supported by a grant from the Robert Wood Johnson Foundation to the University of Texas Southwestern Medical Center (Dr. Rush). It was also supported by National Institute of Mental Health (NIMH) grant MH01697 (Dr. Hollon).

This article is based on papers presented by the authors to the Consensus Conference on "Integrating Psychotherapy into Medication Algorithms for Mood Disorders" held in Dallas, Tex., January 24, 2002.

Financial disclosure appears at the end of this article.

Corresponding author and reprints: Steven D. Hollon, Ph.D., Department of Psychology, Vanderbilt University, 306 Wilson Hall, Nashville, TN 37203 (e-mail: steven.d.hollon@vanderbilt.edu).