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Examination of the Utility of Psychotherapy for Patients with Treatment Resistant Depression: A Systematic Review

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Abstract

OBJECTIVE

To examine the utility of psychotherapy in managing treatment resistant depression.

DATA SOURCES

PubMed, PsycInfo, Embase, Cochrane Registry of Controlled Clinical Trials, article bibliographies.

REVIEW METHODS

Eligible articles had to be in English and include English-speaking adult outpatients from general medical or mental health clinics. Studies had to be randomized clinical trials (RCT) involving at least one of the following psychotherapy modalities: cognitive therapy, interpersonal therapy, or behavior therapy. Patients were considered treatment resistant if they reported partial or no remission following treatment with an adequate antidepressant dose for ≥6 weeks. Exclusion criteria included receiving psychotherapy at the time of recruitment, and/or comorbid psychiatric conditions unlikely to be treated outside of specialized mental health care (e.g., severe substance abuse). Due to heterogeneity in study designs, a summary estimate of effect was not calculated. Studies were critically analyzed and a qualitative synthesis was conducted.

RESULTS

Of 941 original titles, 13 articles evaluating 7 unique treatment comparisons were included. Psychotherapy was examined as an augmentation to antidepressants in five studies and as substitution treatment in two studies. A total of 592 patients were evaluated (Mean age ~40 y; Females = 50-85%; Caucasians ≥75%). The STAR*D trial used an equipoise stratified randomization design; the remaining studies were RCTs. Compared to active management, two good quality trials showed similar benefit from augmenting antidepressants with psychotherapy; one fair quality and one poor quality trial showed benefit from psychotherapy augmentation; and one good and one poor trial found similar benefit from substituting psychotherapy for antidepressants. One fair quality trial showed lithium augmentation to be more beneficial than psychotherapy.

CONCLUSIONS

Review demonstrates the utility of psychotherapy in managing treatment resistant depression. However, evidence is sparse and results are mixed. Given that quality trials are lacking, rigorous clinical trials are recommended to guide practice. In the interim, primary care providers should consider psychotherapy when treating patients with treatment resistant depression.

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Acknowledgments

We would like to thank the VHA Office of Quality Performance for their support in completing the original report on which this manuscript is based. We would like to thank the project staff at the Durham VA Evidence-based Practice Center for their administrative support. Finally, we would like to thank the peer reviewers of the original evidence synthesis and the initial manuscript submission. Their comments and suggestions greatly improved the report and have been incorporated into this manuscript.

Dr. Trivedi was partly supported by an AHRQ T-32 fellowship at Duke University Medical Center, and resources within the VA Puget Sound Health Care System. Dr. Nieuwsma was partly supported by a VA Mid-Atlantic MIRECC fellowship. The views and opinions in this manuscript are those of the authors and do not reflect those of the VA.

This project was funded by the VA Health Services Research and Development Evidence Synthesis Program.

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None disclosed.

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Correspondence to Ranak B. Trivedi PhD.

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Trivedi, R.B., Nieuwsma, J.A. & Williams, J.W. Examination of the Utility of Psychotherapy for Patients with Treatment Resistant Depression: A Systematic Review. J GEN INTERN MED 26, 643–650 (2011). https://doi.org/10.1007/s11606-010-1608-2

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