Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta (Dunlop, LoParo, Kinkead, Mletzko-Crowe, Mayberg, Craighead); Research Design Associates, Inc., Yorktown Heights, New York (Cole); Institute for Early Life Adversity Research, University of Texas Dell Medical School at Austin (Nemeroff); Departments of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York (Mayberg); Department of Psychology, Emory University, Atlanta (Craighead).
Am J Psychiatry. 2019 Apr 1;176(4):275-286. doi: 10.1176/appi.ajp.2018.18091075. Epub 2019 Feb 15.
Adults with major depressive disorder frequently do not achieve remission with an initial treatment. Addition of psychotherapy for patients who do not achieve remission with antidepressant medication alone can target residual symptoms and protect against recurrence, but the utility of adding antidepressant medication after nonremission with cognitive-behavioral therapy (CBT) has received little study. The authors aimed to evaluate the acute and long-term outcomes resulting from both sequences of combination treatments.
Previously untreated adults with major depression who were randomly assigned to receive escitalopram, duloxetine, or CBT monotherapy and completed 12 weeks of treatment without achieving remission entered an additional 12 weeks of combination treatment. For patients who did not achieve remission with CBT, escitalopram was added (CBT plus medication group) to their treatment, and for those who did not achieve remission with an antidepressant, CBT was added (medication plus CBT group) to their treatment. Patients who responded to the combination treatment entered an 18-month follow-up phase to assess risk of recurrence.
A total of 112 patients who did not achieve remission with a monotherapy entered combination treatment (41 who responded to monotherapy but did not achieve remission and 71 who did not respond to monotherapy). Overall, remission rates after subsequent combination therapy were significantly higher among patients who responded to monotherapy but did not achieve remission (61%) than among patients who did not respond to monotherapy (41%). Among patients who responded to monotherapy but did not achieve remission, the remission rate in the CBT plus medication group (89%) was higher than in the medication plus CBT group (53%). However, among patients whose depression did not respond to monotherapy, rates of response and remission were similar between the treatment arms. Higher levels of anxiety, both prior to monotherapy and prior to beginning combination treatment, predicted poorer outcomes for both treatment groups.
The order in which CBT and antidepressant medication were sequentially combined did not appear to affect outcomes. Addition of an antidepressant is an effective approach to treating residual symptoms for patients who do not achieve remission with CBT, as is adding CBT after antidepressant monotherapy. Patients who do not respond to one treatment modality warrant consideration for addition of the alternative modality.
患有重度抑郁症的成年人在初始治疗后经常无法缓解。对于单独使用抗抑郁药物未缓解的患者，添加心理治疗可以针对残留症状并预防复发，但在认知行为疗法（CBT）未缓解后添加抗抑郁药物的效果研究甚少。作者旨在评估联合治疗的两种顺序的急性和长期结果。
以前未经治疗的患有重度抑郁症的成年人被随机分配接受依他普仑、度洛西汀或 CBT 单一疗法治疗，并在未缓解的情况下完成 12 周的治疗后进入另外 12 周的联合治疗。对于 CBT 未缓解的患者，在其治疗中添加依他普仑（CBT 加药物组），对于未缓解的抗抑郁药患者，在其治疗中添加 CBT（药物加 CBT 组）。对联合治疗有反应的患者进入 18 个月的随访阶段，以评估复发风险。
共有 112 名未缓解的单一疗法患者进入联合治疗（41 名对单一疗法有反应但未缓解，71 名对单一疗法无反应）。总体而言，在对单一疗法有反应但未缓解的患者中，随后联合治疗后的缓解率明显高于对单一疗法无反应的患者（61%对 41%）。在对单一疗法有反应但未缓解的患者中，CBT 加药物组（89%）的缓解率高于药物加 CBT 组（53%）。然而，在对单一疗法无反应的抑郁症患者中，两种治疗组之间的反应和缓解率相似。在开始单一疗法和开始联合治疗之前，较高水平的焦虑均预示着两种治疗组的预后较差。
CBT 和抗抑郁药物的先后顺序似乎并未影响结果。对于 CBT 未缓解的患者，添加抗抑郁药是治疗残留症状的有效方法，在抗抑郁药物单一疗法后添加 CBT 也是如此。对于一种治疗方式无反应的患者，应考虑添加另一种治疗方式。
