Combining Drug Therapy and Psychotherapy for Depression

It was just over a generation ago that the routine combination of psychotherapy and drug therapy seemed impossible. Especially in America, psychiatry was polarized by ideologic and political struggles between psychoanalysis and biologic psychiatry. American psychoanalysts tended to regard psychopharmacology as an inferior treatment that covered over problems rather than addressing them. They assumed that symptoms suppressed by drugs would eventually be replaced by others equally disabling. In turn, proponents of biologic psychiatry often viewed psychoanalysis as a form of quackery that was, at best, a costly waste of time, and, at worst, heightened distress that the psychopharmacologist was trying to ameliorate. Benefits of combined treatment In the 1970s, a number of influential studies cut through ideologic assumptions and began to reshape the way we viewed the practice of combining therapy and medications. Klerman and coworkers1 tested the assumption that psychotherapy and psychopharmacology were essentially in conflict, each undermining the work of the other. There was no evidence that psychopharmacologic treatment led to therapy discontinuation or to symptom substitution or that psychotherapy exacerbated patients' distress. Then, Luborsky and colleagues,2 in a meta-analysis comparing the effectiveness of different psychodynamic psychotherapies, made an interesting discovery. All therapies were equally effective, with one notable exception: combined treatment with psychotherapy and medication was found to be notably superior to either treatment alone. Since then, numerous studies have shown combined treatment for depression to have many benefits over single-modality treatment (Table 1). This applies not only to psychodynamic therapy, but also to interpersonal therapy (IPT), a manualized descendent of psychodynamic psychotherapy.3 The evidence was less clear for cognitive-behavioral therapies (CBT), with several early studies showing only nonsignificant trends toward a benefit of combined treatment.4 It appears, however, that this may reflect limitations in study design typical of that period.5 Other studies showed a benefit to combining CBT and pharmacotherapy.6-8