Combined treatment of depression.

Multiple medications and some forms of psychotherapy have demonstrated efficacy in the treatment of depression. However, despite these interventions, many patients continue to respond only partially to available treatments and nonadherence to medication is common, adding to the tendency of depression to recur. Many clinicians believe that a combination of medication and psychotherapy provides the greatest potential for long-term relief of depression, and a number of studies have focused on the relative value of combined compared to single treatments. Given our current state of knowledge, for which patients should a combination of medication and psychotherapy be recommended and employed? The American Psychiatric Association Practice guideline for the treatment of patients with major depressive disorder identifies a broad range of conditions for which combined treatment should be considered (Box 1): “Combining a depression-focused psychotherapy and pharmacotherapy may be a useful initial treatment choice for patients with moderate to severe major depressive disorder. Other indications for combined treatment include chronic forms of depression, psychosocial issues, intrapsychic conflict, interpersonal problems, or a co-occurring Axis II disorder. In addition, patients who have had a history of only partial response to adequate trials of single treatment modalities may benefit from combined treatment. Poor adherence with pharmacotherapy may also warrant combined treatment with medications and psychotherapy focused on treatment adherence.” There are several reasons to believe that medication and psychotherapy should be utilized together for treatment of depression. These approaches probably affect different areas of the brain, potentially creating a synergistic neurophysiologic effect. Given that different patients demonstrate different responses to various treatments, combining two treatments increases the likelihood patients will respond to at least