Efficacy of combined, sequential and crossover psychotherapy and pharmacotherapy in improving outcomes in depression.

There is a growing recognition that relapse and recurrence after the successful treatment of major depression is a common and debilitating outcome that has massive social costs. Although many patients achieve a sustained recovery with maintenance pharmacotherapy, the long-term outcome for a significant proportion of patients is still poor. The purpose of this review is to evaluate the role of combined psychological and pharmacological therapies in minimizing relapse and recurrence in the treatment of depression. Three approaches have been investigated: concurrent treatment, sequential treatment and crossover treatment. Concurrent therapy is as effective as monotherapy for the treatment of mild-to-moderate depressive disorder and shows evidence of a potential treatment advantage in cases where depression is more severe. Consecutive sequencing of pharmacotherapy and psychotherapy has demonstrated some benefit for both the conversion of partial to full response and the prevention of relapse and recurrence, especially in more severely depressed patients. Crossover treatments during the maintenance phase (i.e., switching patients from one treatment to a second after an adequate response to the first) show evidence of being beneficial in preventing relapse and recurrence. Variants of cognitive therapy that have been modified to specifically address residual symptoms in patients who have recovered from depression appear to be the most effective. A review of the studies to date indicates that cognitive therapy may play a role in improving remission rates and decreasing relapse and recurrence rates. Although most studies are small, there is a consistent suggestion of superior prophylaxis for patients receiving some type of sequenced or crossover treatment in which the delivery of antidepressant medication and structured antidepressant psychotherapy is combined. These approaches warrant greater attention; they may present another route for enhancing long-term recovery from major depression.