Treatment

The Talking Therapy Turbocharge

Meds plus talking therapy may be more powerful than either alone.

Is there a way to turbocharge your antidepressant?

A study published by Martin Keller MD of Brown University et al in the May 18, 2000 New England Journal of Medicine compared the antidepressant Serzone with the talking therapy, cognitive behavioral-analysis system of psychotherapy (CBASP). CBASP is largely derivative of other talking therapies such as cognitive, behavioral, and interpersonal therapy. Six hundred eighty-one patients with severe chronic depression (some with other psychiatric illnesses) were enrolled in the trial, and were assigned to either Serzone, CBASP, or combination Serzone-CBASP for 12 weeks. The response rates to either Serzone or CBASP alone were rather underwhelming - 55 percent and 52 percent, respectively, for the 76 percent who completed the study. In other words, a little more than half of the completers in those two arms of the trial reduced their depression by 50 percent or better.

The Serzone findings roughly correspond with many other trial results for antidepressants, and underscore a major weakness in these drugs - that while they are effective, the benefit is often marginal and the treatment outcome problematic. Similarly, the CBASP findings validate other studies finding talking therapy about equal in efficacy to taking antidepressants.

The results for the combination drug-therapy group, however, were truly eye-popping, with 85 percent of the completing patients achieving a 50 percent reduction in symptoms or better. Forty-two percent in the combination group achieved remission (a virtual elimination of all depressive symptoms) compared to 22 percent in the Serzone group and 24 percent in the CBASP group.

The authors of the study confessed to being caught by surprise by the results, acknowledging that "the rates of response and remission in the combined-treatment group were substantially higher than those that might have been anticipated ..."

Clearly, two therapies together represent one of those rare cases of one plus one equals three. In its Treatment Recommendations for Patients with Major Depressive Disorder published in 2000, the American Psychiatric Association advises that patients with major depression may benefit from combined medication and psychotherapy while those with minor depression may opt for talking therapy alone. In its Practice Guideline for the Treatment of Patients with Bipolar Disorder released in 2002, the APA also recommends adding talking therapy to medications therapy for the treatment of bipolar depression.

Cognitive Therapy et al

The main talking therapies used for depression are manual-based and time-limited, generally from 10 to 20 sessions, focusing on the present, and aimed at undoing the type of thoughts, behaviors, and social stressors that conspire against recovery, namely:

Cognitive therapy, also called cognitive behavioral therapy, which teaches the individual to change his or her distorted negative thoughts into more realistic positive ones, such as turning "it's the end of the world" into "let's see how we can manage this."
Behavioral therapy, which can be part of the cognitive behavioral package, focusing on activity scheduling, self-control, and problem solving.
Interpersonal therapy, which assists patients through life's transitions and overcoming deficits in social skills.

Sticking to the manual is paramount. At a symposium at the American Psychiatric Association's annual meeting in May 2002, Michael Thase MD of the University of Pittsburgh and one of the co-authors of the Serzone-CBASP study, pointed out that when talking therapy deteriorated into conversation it did not work.

At a different symposium at the same APA annual meeting, John Markowitz MD of Cornell University, one of the co-authors of the Serzone-CBASP study, noted that medications work faster than talking therapy, but talking therapy can remove potential triggers likely to result in relapse. If you are in a terrible marriage, for example, and you take an antidepressant, you may be in a better position to work on that bad marriage. But if you fail to work on that bad marriage, your unresolved situation will catch up to you, he advised.

Another important benefit of talking therapy, said Dr Markowitz, is that it enhances medications compliance.

At the same symposium, Ellen Frank PhD of the University of Pittsburgh recounted the case of a 28-year-old graduate student having to deal with the sudden death of her mother, a conflict with her thesis advisor, and a shift in her relationship with her father as a result of her mother's death. Using the skills she learned from interpersonal therapy, the student was able to resolve her dispute with her father, and her depression subsequently remitted.

At the Fourth Annual Conference on Bipolar Disorder in Pittsburgh the year before, Dr Frank outlined a hybrid of interpersonal therapy she has created called "interpersonal and social rhythm therapy" for managing the chaos that erupts from bipolar disorder. The therapist will work with the patient in finding the most unstable lifetime rhythms and set goals for change, meanwhile searching for triggers (such as missing sleep) likely to result in disruptions.

At the 2003 APA annual meeting, David Miklowitz PhD of the University of Colorado reported on two 2003 studies that found family focused therapy, which educates patients and family in illness insight and management, resulted in better meds compliance and delayed relapses into bipolar episodes compared to a group of patients receiving meds and crisis management therapy. Similarly, two recent studies have found cognitive therapy and psychodeducation delayed times to recurrence.

Breakthrough Finding

In findings released online in Dec 2003 by the National Academy of Sciences, Keller et al (this time with Charles Nemeroff MD, PhD of Emory University as the lead author) had another look at the Serzone/CBASP study data, and what they discovered was no less startling than their original finding: While there was little difference between antidepressant and talking therapy among the patients with no early childhood trauma, those who had lost their parents at an early age, been physically or sexually abused, and/or neglected fared significantly better on talking therapy than on an antidepressant.

That study represents an important breakthrough in the quest of matching patients to treatments, though much more research is needed. Unfortunately, talking therapy has traditionally been the poor relation when it comes to research dollars. That may change, however, as the pharmaceutical industry begins to appreciate how "the competition" can add value to its products. According to Dr Thase at the APA meeting, Bristol-Myers Squibb spent $26 million on the Serzone-CBASP study. Hopefully, we will see more studies like this. In the meantime, as the Serzone-CBASP study makes abundantly clear, there is no reason for psychiatry and psychology to be at odds with one another. Medication therapy has its limits, as does talking therapy, but the two together hold out high hopes for success.

Updated Jan 2, 2004, reviewed Feb 10, 2008