|Year : 2022 | Volume
| Issue : 3 | Page : 178-188
The efficacy of short-term individual interpersonal psychotherapy in augmentation with pharmacotherapy in major depressive disorder
Ahmed Dobie1, Salwa Tobar2, Mohamed El-Hadidy2, Ahmed Eissa3
1 Department of psychiatry, Dakahlia Mental Hospital, Dakahlia, Egypt
2 Department of Psychiatry, Mansoura University, Mansoura, Egypt
3 Department of Neuropsychiatry, Port Said University, Port Said, Egypt
|Date of Submission||27-Feb-2022|
|Date of Decision||15-Apr-2022|
|Date of Acceptance||23-May-2022|
|Date of Web Publication||16-Dec-2022|
MD Ahmed Eissa
Assistant professor of neuropsychiatry, Faculty of medicine, Port Said University, 23 December street beside Port Said Mental Hospital, Alzohour, Port Said, 42511
Source of Support: None, Conflict of Interest: None
Background The high prevalence rates and persistently increasing burden of depression indicate that there are still many unmet needs in the management of depression. Interpersonal psychotherapy (IPT) is one of the main evidence-based psychotherapeutic interventions for depression.
Aim To evaluate the efficacy of short-term individual IPT in combination with pharmacotherapy, compared with pharmacotherapy alone, in the treatment of depression and assess its role in improving social functioning.
Setting and design This study was conducted in Mansoura University hospitals and was an interventional randomized controlled trial.
Patients and methods A total of 40 patients were recruited and randomized into either the interventional group or the control group. The interventional group received IPT in combination with selective serotonin reuptake inhibitor. IPT was in the form of once weekly session for 12 weeks. Patients in the control group received treatment with an selective serotonin reuptake inhibitor with appointments once every 2 weeks. Patients from both groups were assessed by the Montgomery–Asberg Depression Rating Scale and the Social Adjustment Scale Self-Report at the beginning and after 12 weeks.
Statistical analysis IBM SPSS Statistics version 20.0 was used for statistical analysis.
Results There were highly statistically significant improvements in depressive symptoms and in social functioning between the baseline assessments and after 12 weeks on the used scales in both groups. There was a trend for better improvement in the interventional group (IPT+pharmacotherapy) in depressive symptoms and in overall and specific domains of social functioning when compared with the control group. The interventional group showed statistically significant better improvements in social functioning when compared with the control group.
Conclusions Combined IPT and pharmacotherapy shows clear benefits over pharmacotherapy alone, in both alleviating depressive symptoms and improvement of social functioning.
Keywords: combined psychotherapy and pharmacotherapy, depression, interpersonal psychotherapy
|How to cite this article:|
Dobie A, Tobar S, El-Hadidy M, Eissa A. The efficacy of short-term individual interpersonal psychotherapy in augmentation with pharmacotherapy in major depressive disorder. Egypt J Psychiatr 2022;43:178-88
|How to cite this URL:|
Dobie A, Tobar S, El-Hadidy M, Eissa A. The efficacy of short-term individual interpersonal psychotherapy in augmentation with pharmacotherapy in major depressive disorder. Egypt J Psychiatr [serial online] 2022 [cited 2023 Nov 30];43:178-88. Available from: https://new.ejpsy.eg.net//text.asp?2022/43/3/178/363997
| Background|| |
Depression is ranked the second leading cause of disability globally in all ages and sexes (Ferrari et al., 2013; Gutiérrez-Rojas et al., 2020). The high prevalence rates and persistently increasing burden of depression indicate that there are still many unmet needs in the management of depression (World Health Organization, 2015; Wittchen et al., 2001; Tolin, 2010).
Successful treatment of depression is influenced by many factors beyond the properties of a particular medication. These include the unique characteristics of each patient, the safety–tolerability–effectiveness profile of the drug, and the interaction between patient and health care professionals (Butcher et al., 2008). Although newer antidepressants represent significant improvements in safety and tolerability, the advances in therapeutic benefit are not substantial. Shortcomings of current antidepressants include the delayed achievement of benefit, the percentage of patients not reaching response or remission, the continuity of adverse effects, and ∼25% recurrence risk even if continued to be taken during maintenance (Kennedy et al., 2006; Parker and Fletcher, 2007; Solomon et al., 2008). Moreover, some patients do not respond to medications, or refuse to take them, or in many areas of the world just cannot afford them. For all of these patients, psychotherapies may have a utility (National Institute for Clinical Excellence NICE, 2004; American Psychiatric Association, 2010).
In practice, guidelines recommend both pharmacological and psychological interventions for depressive disorders (Ellis, 2004; National Institute for Clinical Excellence NICE, 2004).
The effectiveness of psychotherapy is documented by decades of scientific research (Wampold, 2010; Chorpita et al., 2011; Cuijpers et al., 2016). Thousands of quantitative and qualitative studies have shown that ∼75–80% of patients who receive psychotherapy show benefit (Halverson, 2020; Pampallona et al., 2004; Lambert, 2010).
Cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) have been proven to be the best psychotherapy candidates to be used in combination with pharmacotherapy in the treatment of major depressive disorder (MDD) (Sudak, 2011; Cuijpers et al., 2016). Both CBT and IPT are diagnosis-targeted, time-limited treatments that enable patients to re-claim control of their mood and functioning (Stuart and Robertson, 2012; Markowitz et al., 2014; Pu et al., 2017).
IPT is based on the link between depression and interpersonal life events. Within IPT, therapy focuses on the interpersonal relations as a way to bring out change, either through improving the interpersonal relationships or changing patients’ expectations about them (Stuart and Robertson, 2012). IPT was developed for various types of clinical trials. For acute treatment trials, the length has ranged from 12 to 16 weeks; for continuation trials, weekly for 8 months; and for maintenance trials continued for three years (Cuijpers et al., 2016). Weissman and other colleagues have proven the efficacy of IPT in the treatment of depression repeatedly in many clinical trials, and this success has led to its modification for use in other mood and non-mood disorders (Cuijpers et al., 2016). Some trials have demonstrated the efficacy of IPT in treatment of depression in medically ill patients, peripartum women, depressed adolescents, geriatric depressed patients, and for recurrent or treatment-resistant depression (Pu et al., 2017). Success with mood disorders has also led to the exploration of IPT as a treatment for other conditions. There have been promising developments of IPT as a treatment for social phobia, post-traumatic stress disorder, and eating disorders. IPT has also shown preliminary benefits for anxiety disorders (Markowitz et al., 2014).
| Patients and methods|| |
The aim of this study was to evaluate the efficacy of short-term individual IPT in combination with pharmacotherapy, compared with pharmacotherapy alone, in the treatment of MDD, and assess its role in alleviating depressive symptoms and improving social functioning in a sample of Egyptian adult patients.
The design of this study is an interventional randomized controlled trial, with two parallel arms. This study was approved by the Mansoura Research Ethical Committee and was performed according to the ethical standards of the Helsinki Declaration. All included participants signed an informed consent form after explaining to them the details of the research goals, ensuring the confidentiality of the obtained data, and acknowledging their voluntary participation.
The study took place in the Mansoura University hospital psychiatry outpatient clinic, Dakahlia mental health hospital outpatient clinic, and some referred patients from private clinics in Mansoura city, Egypt. The study extended for 18 months from April 2014 to October 2015.
A total of 40 patients were recruited from the previously mentioned sites. Inclusion criteria were meeting the ‘DSM-5’ diagnostic criteria of MDD, age from 18 to 60 years old, Egyptian nationality, and giving informed consent. Exclusion criteria were presence of other comorbid psychiatric disorders, presence of comorbid substance-use disorder, presence of a comorbid chronic or severe medical illness, history of a previous ‘manic or mixed or hypomanic episode,’ history of receiving any kind of psychotherapy in the last year, and history of receiving psychotropic or antidepressant medication in the last 3 months.
A total number of 64 patients underwent screening for eligibility, and of those patients, 13 patients did not meet the inclusion criteria and 11 patients refused to participate. The 40 patients who met inclusion criteria and gave informed consent were randomized to either the interventional group (n=20) or the control group (n=20). Randomization was on the basis of alternate allocation.
In the interventional group (n=20), only two patients were withdrawn from the study; one of them due to noncompliance with regular study appointments beyond the minimal acceptable limit, and the other one owing to noncompliance with study medications. In the control group (n=20), three patients were withdrawn from the study, all of them due to noncompliance with study medications. All five withdrawn patients were excluded from the statistical analysis of results.
The patients in the interventional group received individual IPT in combination with an selective serotonin reuptake inhibitor (SSRI) antidepressant (Escitalopram). IPT was in the form of once weekly session for 12 consecutive weeks (12 sessions). The minimum number of sessions accepted to fulfill the definition of sufficient therapy was ten sessions. Patients in the control group received ‘treatment as usual’ in combination with escitalopram. ‘Treatment as usual’ appointments in the control group were arranged to be once every 2 weeks for 12 weeks (six appointments). Patients in the interventional group also received treatment as usual, besides IPT. Treatment as usual included clinical assessment, checking for adverse effects, and unstructured psycho-education.
Patients with mild or moderate depression were administered escitalopram at a dosage of ten milligrams daily, whereas patients with severe depression were administered 10 mg daily during the first week, and 20 mg daily thereafter. This scheme was used for patients in both the interventional and control groups. Pharmacotherapy adherence and adverse effects were assessed using patient self-report. Patients in both groups were assessed by the Montgomery–Asberg Depression Rating Scale (MADRS) and the Social Adjustment Scale Self-Report (SAS-SR) twice during the study period: the first assessment at baseline before starting IPT or escitalopram, and the second assessment at the end of 12 weeks.
Efficacy was determined by intragroup differences and intergroup differences at two assessment points: at baseline and after 12 weeks. The primary domains assessed were depressive symptoms as measured by the clinician-rated MADRS and social functioning as measured by the SAS-SR.
The outcome measures are first MADRS (Montgomery and Asberg, 1979), which is used to assess the severity of depression among depressive patients. It is a 10-item diagnostic questionnaire. Every item has a score of 0–6, with the overall score ranging from 0 to 60. Higher MADRS score indicates more severe depression (McDowell, 2006; Williams and Kobak, 2008). It includes questions on the following symptoms: sadness (apparent), sadness (reported), inner tension, decreased sleep, reduced appetite, lassitude, concentration difficulties, inability to feel, pessimistic thought, and suicidal thoughts (Davidson et al., 1986).
Herrmann et al. ((1998)) proposed the following cutoff scores from 0 to 8=remission/symptoms absent, nine to 17=mild depression, 18–34=moderate depression, and more than or equal to 34=severe depression. The cutoff scores used in this study were those proposed by Herrmann et al. ((1998)) as those are most commonly used in clinical trials (Müller-Thomsen et al., 2005; McDowell, 2006).
The principal outcome measure in this study was the difference between the MADRS scores at baseline and those after 12 weeks. A 50% or more reduction in MADRS score at the endpoint from baseline score was used as an indicator of response (Frank, 1991), and an endpoint MADRS score of ten or less was used as an indicator of remission (Hawley et al., 2002). A 50% or more reduction in MADRS score with and endpoint score of more than ten is classified as a ‘response without remission.’ A reduction in MADRS score at the endpoint of less than 50% is an indicator of nonresponse.
The second is the SAS-SR (Weissman and Bothwell, 1976; Weissman, 1999; Weissman et al., 2001), which was designed as an outcome measure to evaluate drug treatment and psychotherapy for depressed patients. It is a 54-item paper-and-pencil self-report scale of social adjustment derived directly from the SAS interview, with wording of the questions changed to suit the self-report format. The self-report version has the advantage of being free from interviewer bias (Weissman and Bothwell, 1976). The scale includes a total of 54 questions, of which respondents answer 42 questions, which is because the method provides alternative questions on work relations for employed people, housewives, and students. It takes 20–30 min to complete. The questions were designed to measure expressive and instrumental performance over the past 2 weeks in six role areas: work, social and leisure activities, relationships with extended family, role as a marital partner, role as a parent, and role as a member within the family unit, including perceptions about economic functioning (Gurland et al., 1972). Questions in each role area cover four expressive and instrumental categories. Each question is rated on a five-point scale, with higher scores indicating more impairment. The SAS-SR generates seven mean scores: one for each of the six role areas, plus a score for the overall mean. The scores of items within each role area are summed and a mean for each role area is obtained, and an overall adjustment score is obtained by summing the scores of all items and dividing it by the total number of items answered.
An Arabic version of the SAS-SR was used after a process of translation and back-translation. The Arabic version was approved and verified through the department of foreign languages in the Faculty of Education in Mansoura University.
IPT is a time-limited diagnosis-based treatment originally used for patients with MDD, but later adapted for other disorders as well (Frank et al., 2007). IPT was described in a manual by Klerman et al. ((1984)) and was updated by Weissman et al. (2000, (2007)). Five different phases exist in the IPT approach: assessment phase, initial phase, middle phase, termination phase, and maintenance phase. In the assessment phase, a standard clinical interview is completed to determine the suitability of IPT for the patient. The therapist then proceeds through the initial phase of IPT with the goal of socializing the patient to IPT and creating the IPT focus. Then an interpersonal inventory and an interpersonal formulation are developed, and a contract is made with patient for a certain number of sessions (Stuart and Robertson, 2012). During the middle phase, the therapist and the patient address relevant problem areas using key IPT techniques (ideally one but can be more). In the termination phase, the therapist reviews progress in the problem areas with the patient and together plan for future problems. Maintenance sessions can continue to prevent relapse or to work through any unsolved problems, but after the negotiation of a new contract (Stuart and Robertson, 2012).
This study included the acute treatment phase only. IPT was administered weekly for 12 weeks, with the session length between 40 and 50 min. Of 18 patients who completed IPT, 15 received the 12 sessions throughout 12 weeks as planned. However, three patients missed two sessions and needed two more weeks to account for the missed sessions and complete the 12 sessions.
Regarding MDD treatment in adults, systematic reviews and meta-analyses continue to support the idea that all the SSRIs have similar effectiveness, efficacy, and effects on quality of life. However, some clinically important differences among specific drugs do exist with respect to the onset of action and side effects (Halverson, 2020). Escitalopram was chosen in this study to represent pharmacological treatment of MDD with SSRIs. Escitalopram, the active isomer of citalopram, is a highly SSRI and has shown better efficacy in the treatment of severe depression, both in effect size and time of onset of action (Azorin et al., 2004). It is well tolerated in MDD; adverse events are generally mild to moderate and transient, and no additional events are observed with long-term use. In a recent multiple-treatment meta-analysis, escitalopram and sertraline have shown the best profile of acceptability (Cipriani et al., 2009).
All of the data were collected, formulated, and statistically analyzed using ‘IBM SPSS Statistics’ version 20.0. (IBM Corp., Released 2011, Armonk, New York, USA).
| Results|| |
The sociodemographic characteristics of patients in both interventional and control groups were comparable regarding age, sex, marital status, current living condition, residence, education, and employment, with no statistically significant difference between the two groups ([Table 1]).
|Table 1 Sociodemographics of patients in both interventional (interpersonal psychotherapy+selective serotonin reuptake inhibitor) and control (selective serotonin reuptake inhibitor) groups|
Click here to view
[Table 2] presents the baseline clinical characteristics of patients in both interventional and SSRI groups. There was no statistically significant difference between the two groups. As shown, the two groups were matched and comparable regarding the number of previous episodes, the age of the first episode, the duration of the current episode, and the severity rating of the current depressive episode on the MADRS.
|Table 2 Clinical characteristics of patients in both interventional (interpersonal psychotherapy+selective serotonin reuptake inhibitor) and control (selective serotonin reuptake inhibitor) groups|
Click here to view
Regarding the number of previous episodes, 47.5% of patients had no previous depressive episodes, 27.5% had a single previous episode, 17.5% with two previous episodes, and 7.5% with three previous episodes. Regarding the age of the first depressive episode, 45% of patients had their first depressive episode in the 18–30-year age group, 25% in the 31–40-years age group, 17.5% in the 41–50-year age group, and 12.5% in the 51–60-year age group. Considering the duration of the current depressive episode, the sample included 75% of patients with a duration of less than 1 year, 17.5% with a duration between 1 and 2 years, and 7.5% with a duration of more than 2 years.
Regarding the severity rating of the current depressive episode on the MADRS, based upon previously defined cutoff scores, the sample included 20% of patients with mild depression, 42.9% with moderate depression, and 37.1% with severe depression. There was no statistically significant difference between the two groups. The interventional (IPT) group included 20% of patients with mild depression, 45% with moderate depression, and 35% with severe depression. The controls group included 25% of patients with mild depression, 40% with moderate depression, and 35% with severe depression.
[Table 3] shows the intragroup differences between measurements at baseline and after 12 weeks, expressed in mean MADRS scores. As shown, both groups reported significant improvement in depressive symptoms, and intragroup differences between baseline and week 12 assessments are highly statistically significant in both groups.
|Table 3 Intragroup comparison of both interventional and control groups between baseline and after 12 weeks|
Click here to view
In addition, SAS-SR scores, in both groups, showed significant improvement in overall social functioning, and intragroup differences between baseline and week 12 assessments were highly statistically significant in both groups.
[Table 4] presents the intergroup differences between measurements at baseline and after 12 weeks, expressed in mean MADRS and SAS-SR scores. At baseline, there were no significant differences in depressive symptoms on the MADRS and also in the level of overall social functioning on the SAS-SR between both groups, denoting successful randomization. Regarding the assessment after 12 weeks, there were no statistically significant intergroup differences detected on the MADRS (P=0.309). However, patients in the IPT group compared with those in the control group have shown notable greater decreases in depressive symptoms. On the contrary, the intergroup differences in the mean SAS-SR scores after 12 weeks showed that patients in the IPT group, compared with patients in the control group, reported significantly greater improvement in overall social functioning, resulting in a highly statistically significant intergroup difference (P<0.001).
|Table 4 Intergroup comparison at baseline and after 12 weeks between interventional and control groups|
Click here to view
[Table 5] presents the outcome, in terms of response/nonresponse, and remission/nonremission in both groups. Thus, for both response and remission parameters, there was a remarkable greater difference in favor of the IPT group, but still statistical significance could not be detected.
|Table 5 Intergroup comparison of response and remission rates on the Montgomery–Asberg Depression Rating Scale after 12 weeks|
Click here to view
[Table 6] presents the mean MADRS scores, at baseline and after 12 weeks, according to baseline depression severity, in the IPT group and control group, respectively. As shown, there was a highly statistically significant difference, with respect to depression severity, at baseline in both groups, but after 12 weeks, a statistically significant difference was in the control group only.
|Table 6 Mean Montgomery–Asberg Depression Rating Scale scores at baseline and after 12 weeks according to baseline depression severity|
Click here to view
[Table 7] presents the intergroup differences between measurements at baseline and after 12 weeks in the six role areas of social functioning. At baseline, there were no significant differences in the level of social functioning in any of the six role areas, between both groups, denoting successful randomization. After 12 weeks, patients in the IPT group, compared with patients in the control group, reported significantly greater improvement in four role areas of social functioning. As shown, intergroup difference in the remaining two role areas were also very close to statistical significance.
|Table 7 Intergroup comparison of Social Adjustment Scale Self-Report role areas mean scores at baseline and after 12 weeks|
Click here to view
[Table 8] presents the correlations in the IPT group between the MADRS scores and the SAS-SR scores, at baseline and after 12 weeks. There was a highly statistically significant strong positive correlation between the MADRS scores at baseline and the SAS-SR scores at baseline. In addition, there is a highly statistically significant moderate positive correlation between the MADRS scores after 12 weeks and the SAS-SR scores after 12 weeks.
|Table 8 Correlations between Montgomery–Asberg Depression Rating Scale and Social Adjustment Scale Self-Report at baseline and after 12 weeks in the interventional group|
Click here to view
| Discussion|| |
In terms of mean MADRS scores, the highly statistically significant intragroup differences between baseline and week 12 assessments in both groups corroborate the widely held view that both pharmacotherapy and combined therapy are efficacious treatments of depression. Several systematic reviews have examined the effects of both psychotherapy and pharmacotherapy and have shown that both therapeutic interventions are effective in the treatment of depressive disorders (Cuijpers et al., 2008; Cuijpers, 2016; Karyotaki et al., 2016). Moreover, significant improvement in overall social functioning was recorded, supporting the widely held view that social functioning and depression are closely related; depression is usually associated with impairment in social functioning, and improvement in depression is associated with improvement in social functioning (Lambert and Ogles, 2004; Lambert, 2010).
Although the difference in assessments after 12 weeks between the two groups on the MADRS were nonstatistically significant, a remarkable difference was shown in favor of the combined therapy group, and the P values suggest that a larger sample size could be able to detect a statistically significant difference between the interventional and control groups. However, there was a significantly greater improvement in overall social functioning in patients in the combined therapy group, compared with patients in the pharmacotherapy group. These findings support the view that IPT combined with pharmacotherapy has a significant additional benefit over pharmacotherapy alone in the improvement of social functioning (Guidi et al., 2011).
In other relevant research, a meta-analysis of IPT for depression by Cuijpers et al. ((2011)) included 10 studies comparing combination of IPT and pharmacotherapy with pharmacotherapy alone and found a difference in favor of combination treatment. Likewise, this difference was not statistically significant, perhaps reflecting the small number of studies and consequent low statistical power (Cuijpers et al., 2011).
In terms of response and nonresponse, 83.3% in the combined therapy group compared with 64.7% in the pharmacotherapy group met the MADRS response criteria. This is a remarkably high difference in response rates between both groups, in favor of the combined therapy group. Response rates in the pharmacotherapy group (64.7%) were very similar to those reported in a meta-analysis on efficacy of SSRIs of 65.8% (Kennedy et al., 2006). Regarding remission and nonremission, 72.22% in the combined therapy group compared with 47.06% in the pharmacotherapy group met the MADRS remission criteria. This is also a remarkably high difference in remission rates between both groups, in favor of the combined therapy group.
Even though there was a remarkably high difference in favor of the IPT group in both response and remission rates, it is most likely that a statistically significant difference could not be detected because of the restricted sample size, and as the P values are very close to significance, it is most probable that a larger sample size could be able to detect a statistically significant difference.
A highly statistically significant difference was found in the intergroup comparison in the severely depressed patient group, in favor of combination therapy. Moreover, comparisons of response and remission rates according to severity have also shown better improvement in the severely depressed patients with combined therapy but not with pharmacotherapy. The intergroup comparison in response and remission rates in patients with severe depression revealed remarkable yet nonstatistically significant differences in favor of the combination therapy group. These findings are similar to those reported by other researchers (Cuijpers et al., 2015).
Several studies suggest that CBT and IPT may have specific effects when competently implemented but only for patients with more severe depression. Among studies that considered balance with respect to severity, specific effects were found nearly only among patients with more severe depression, and that applies with respect to both psychotherapy and medications (Thase and Conolly, 2020; Driessen et al., 2010; Fournier et al., 2010). Some call this the ‘dirty little secret’ of pharmaceutical industry, which has long selectively screened out patients with less severe depression (in order to up the odds of finding drug-placebo differences required to win FDA approval) and then turns around and markets those same medications to people who it knows fully well are likely to respond for purely psychological reasons (Kirsch, 2010).
Intragroup differences between baseline and week 12 assessments on the SAS-SR were highly statistically significant in all the six role areas in both groups. Patients in the IPT group compared with patients in the control group reported significantly greater improvement in four role areas of social functioning (parental, marital, leisure, and extended family role areas). These findings support the view that IPT combined with pharmacotherapy has a significant additional benefit over pharmacotherapy alone in the improvement of social functioning, in both overall functioning and specific role areas (Weissman et al., 2014; Bright et al., 2020). These findings maintain the widely held view that social functioning and depression are closely related; depression is usually associated with impairment in social functioning, and improvement in depression is associated with improvement in social functioning (Kraus et al., 2019).
In relevant research, a recent meta-analysis by Cuijpers ((2016)) found clear evidence that combined treatment with psychotherapy and pharmacotherapy may be the best treatment available for adult depression and that it is significantly more effective than treatment with pharmacotherapy alone (Cuijpers, 2016). However, until now, it has not been well established whether the effects of pharmacotherapy and those of psychotherapy are complementary to each other, or independent from each other, or whether combined treatments lead to higher effects than the sum of the two treatments alone (Friedman et al., 2004; Otto et al., 2005).
According to Stahl ((2012)), there has always been a competition between psychopharmacology and psychotherapy, but as psychopharmacology became the main treatment in psychiatry, this approach is heavily criticized as limited with nonrobust outcomes and affected by the drugs industry. He has shown that the recent advances in neurobiology are illuminating that learning and environmental experiences, such as psychotherapy, change brain circuit, as do drugs. In another way, Stahl considered that psychotherapy, as therapeutic agents, is capable of acting epigenetically in a way similar or complementary to drugs. This view has the potential of making the entire effect greater than the sum of the parts, or 1+1=3, the delightful ‘bad math’ of therapeutic synergy (Stahl, 2012).
The main limitation of this study is its sample size and should be viewed as a preliminary study. Another limitation was the use of a single psychotherapist. Because this is a small study, the provision of IPT by a single therapist decreases generalizability and allows attribution of the results to the therapist rather than the therapy. The question whether specific IPT techniques, or therapeutic factors common to different psychotherapies, contribute more to outcome in psychotherapy is still debatable.
| Conclusions|| |
Both the combined therapy (IPT+SSRI) and pharmacotherapy (SSRI) groups had highly statistically significant and clinically relevant improvements in depressive symptoms and in social functioning, between the baseline assessments and assessments after 12 weeks.
The combined therapy (IPT+SSRI) group showed statistically significantly better improvement in social functioning when compared with the pharmacotherapy (SSRI) group.
The combined therapy (IPT+SSRI) group has shown remarkable but nonstatistically significantly better improvement in depressive symptoms when compared with the pharmacotherapy (SSRI) group.
Patients in the combined therapy (IPT+SSRI) group had remarkably higher response and remission rates than patients in the pharmacotherapy (SSRI) group (83.3% response and 72.22% remission compared with 64.7% response and 47.06% remission, respectively).
Severely depressed patients have shown remarkably better improvement with combined therapy (IPT+SSRI) but not with pharmacotherapy (SSRI) alone.
Larger trials are needed with enough statistical power to detect modest effects when comparing combined therapy with pharmacotherapy in the treatment of depression.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
American Psychiatric Association (2010). Practice guidelines for the treatment of patients with major depressive disorder
. 3rd ed, Arlington, VA: American Psychiatric Publishing Inc.
Azorin JM, Llorca PM, Despiegel N, Verpillat P (2004). Escitalopram is more effective than citalopram for the treatment of severe major depressive disorder. L’Encephale 30:158–166.
Bright KS, Charrois EM, Mughal MK, Wajid A, McNeil D, Stuart S et al.
(2020). Interpersonal psychotherapy to reduce psychological distress in perinatal women: a systematic review. Int J Environ Res Public Health 17:8421.
Butcher JN, Mineka S, Hooley JM (2008). Abnormal psychology
. 14 ed. Boston: Pearson Education Inc.
Chorpita BF, Daleiden EL, Ebesutani C, Young J, Becker KD, Nakamura BJ et al.
(2011). Evidence-based treatments for children and adolescents: an updated review of indicators of efficacy and effectiveness. Clin Psychol Sci Pract 18:154–172.
Cipriani A, Furukawa TA, Salanti G, Geddes JR, Geddes JR, Higgins JP, Churchill R et al.
(2009). Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple- treatments meta-analysis. Lancet 373:746–758.
Cuijpers P, van Straten A, Andersson G, van Oppen P (2008). Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies. J Consult Clin Psychol 76:909–922.
Cuijpers P, Geraedts AS, van Oppen P, Andersson G, Markowitz JC, van Straten A et al.
(2011). Interpersonal psychotherapy for depression: a meta-analysis. Am J Psychiatry 168:581–592.
Cuijpers P et al.
(2015). The combination of psychotherapy and pharmacotherapy in the treatment of adult depression: a comprehensive meta-analysis. J Evid Based Psychother 15:147–168.
Cuijpers P (2016). the future of psychotherapy research: stop the waste and focus on issues that matter. Epidemiol Psychiatr Sci 25:291–294.
Cuijpers P, Donker T, Weissman SS, Ravitz P, Cristea IA (2016). Interpersonal psychotherapy for mental health problems: a comprehensive meta-analysis.Am J Psychiatry 173:680–687.
Davidson J, Turnbull CD, Strickland R, Miller R, Graves K et al.
(1986). The Montgomery Asberg Depression Scale: reliability and validity. Acta Psychiatr Scand 73:544–548.
Driessen E, Cuijpers P, Hollon SD, Dekker JJ. Does pretreatment severity moderate the efficacy of psychological treatment of adult outpatient depression? A meta-analysis. J Consult Clin Psychol 2010; 78:668–680.
Ellis P (2004). Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Depression: Australian and New Zealand clinical practice guidelines for the treatment of depression. Aust NZ J Psychiatry 38:389–407.
Ferrari AJ, Charlson FJ, Norman RE, Patten SB, Murray CJL, Whiteford HA et al.
(2013). Burden of depressive disorders by country, sex, age and year: findings from the Global Burden of Disease Study 2010. PLoS Med 10:e1001547.
Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC, Fawcett J (2010). Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA 303:47–53.
Frank E (1991). Interpersonal psychotherapy as a maintenance treatment for patients with recurrent depression. Psychotherapy 28:259–266.
Frank E, Kupfer DJ, Buysse DJ, Swartz HA, Pilkonis PA, Houck PR et al.
(2007). Randomized trial of weekly, twice monthly, and monthly interpersonal psychotherapy as maintenance treatment for women with recurrent depression. Am J Psychiatry 164:761–767.
Friedman MA, Detweiler-Bedell JB, Leventhal HE et al.
(2004). Combined psychotherapy and pharmacotherapy for the treatment of major depressive disorder. Clin Psychol Sci Pract 11:47–68.
Guidi J, Fava GA, Fava M, Papakostas GI (2011). Efficacy of the sequential integration of psychotherapy and pharmacotherapy in major depressive disorder: a preliminary meta-analysis. Psychol Med 41:321–331.
Gurland BJ, Yorkston NJ, Goldberg K, Fleiss JL, Sloane RB, Cristol AH (1972). The Structured and Scaled Interview to Assess Maladjustment (SSIAM): II. Factor analysis, reliability and validity. Arch Gen Psychiatry 27:264–267.
Gutiérrez-Rojas L, Porras-Segovia A, Dunne H, Andrade-González N, Cervilla JA (2020). Prevalence and correlates of major depressive disorder: a systematic review. Braz J Psychiatry 42:657–672.
Hawley CJ, Gale TM, Sivakumaran T (2002). Defining remission by cut off score on the MADRS: selecting the optimal value. J Affect Disorder 72:177–184.
Herrmann N, Black SE, Lawrence J, Szekely C, Szalai JP (1998). The Sunnybrook Stroke Study: a prospective study of depressive symptoms and functional outcome. Stroke 29:618–624.
Karyotaki E, Smit Y, Holdt Henningsen K, Huibers MJH, Robays J, de Beurs D et al.
(2016). Combining pharmacotherapy and psychotherapy or monotherapy for major depression? A meta‐analysis on the long‐term effects. J Affect Disord 194:144–152.
Kennedy SH, Andersen HF, Lam RW (2006). Efficacy of escitalopram in the treatment of major depressive disorder compared with conventional selective serotonin reuptake inhibitors and venlafaxine XR: a meta-analysis. J Psychiatry Neurosci 31:122–131.
Kirsch I (2010). The Emperor’s new drugs: exploding the antidepressant myth
. New York: Basic Books.
Klerman GL, Weissman MM, Rounsaville BJ et al.
(1984). Interpersonal psychotherapy of depression
. New York, NY: Basic Books.
Kraus C, Kadriu B, Lanzenberger R, Zarate CA, Kasper S (2019). Prognosis and improved outcomes in major depression: a review. Transl Psychiatry 9:127–133.
Lambert JJ, Ogles B M (2004). The efficacy and effectiveness of psychotherapy. In: Lambert MJ, (editor). Bergin and Garfield’s. handbook of psychotherapy and behavior change
. 5th ed. NewYork: Wiley; p139–p193.
Lambert MJ (2010). Prevention of treatment failure: the use of measuring, monitoring, and feedback in clinical practice
. Washington, DC: APA Press.
Markowitz JC, Lipsitz J, Milrod BL (2014). Critical review of outcome research on interpersonal psychotherapy for anxiety disorders. Depress Anxiety 31:316–325.
McDowell I (2006). Measuring health: a guide to rating scales and questionnaires
. 3rd ed. New York: Oxford University Press.
Montgomery SA, Asberg M (1979). A new depression scale designed to be sensitive to change. Br J Psychiatry 134:382–389.
Müller-Thomsen T, Arlt S, Mann U, Maß R, Ganzer S (2005). Detecting depression in Alzheimer’s disease: evaluation of four different scales. Arch Clin Neuropsychol 20:271–276.
National Institute for Clinical Excellence (NICE) (2004). Depression: management of depression in primary and secondary care (National Clinical Practice Guideline 23)
. London: NICE.
Otto MW, Smits JAJ, Reese HE (2005). Combined psychotherapy and pharmacotherapy for mood and anxiety disorders in adults: review and analysis. Clin Psychol Sci Pract 12:72–86.
Pampallona S, Bollini P, Tibaldi G, Kupelnick B, Munizza C (2004). Combined pharmacotherapy and psychological treatment for depression: a systematic review. Arch Gen Psychiatry 61:714–719.
Parker G, Fletcher K (2007). Treating depression with the evidence-based psychotherapies: a critique of the evidence. Acta Psychiatr Scand 115:352–359.
Pu J, Zhou X, Liu L, Zhang Y, Xie P (2017). Efficacy and acceptability of interpersonal psychotherapy for depression in adolescents: a meta-analysis of randomized controlled trials. Psychiatry Res 253:226–232.
Solomon DA, Keitner GI, Ryan CE, Kelley J, Miller IW (2008). Preventing recurrence of bipolar I mood episodes and hospitalizations: family psychotherapy plus pharmacotherapy versus pharmacotherapy alone. Bipolar Disord 10:798–805.
Stahl SM (2012). Psychotherapy as an epigenetic ‘drug’: psychiatric therapeutics target symptoms linked to malfunctioning brain circuits with psychotherapy as well as with drugs. J Clin Pharmacy Therap 37:249–253.
Stuart S, Robertson M (2012). Interpersonal psychotherapy: a clinician’s guide
. 2nd ed. London: Edward Arnold (Oxford University Press).
Sudak DM (2011). Combining CBT and medication: an evidence-based approach. NJ, Hoboken: Wiley.
Thase M, Conolly K (2020). Unipolar depression in adults: choosing treatment for resistant depression. Available at:. http://www.update.com
[Accessed May 5, 2020].
Tolin DF (2010). Is cognitive-behavioral therapy more effective than other therapies? A meta-analytic review. Clin Psychol Rev 30:710–720.
Wampold BE (2010). The basic of psychotherapy: an introduction to theory and practice
. Washington, DC: American Psychological Association.
Weissman MM, Bothwell S (1976). Assessment of social adjustment by patient self-report. Arch Gen Psychiatry 33:1111–1115.
Weissman M (1999). MHS Staff. Social adjustment scale – self-report (SAS-SR) user’s manual. multi-health systems
. New York, North Tonawanda: NY Inc.
Weissman MM, Markowitz JC, Klerman G (2000). Comprehensive guide to interpersonal psychotherapy
. New York, NY: Basic Books.
Weissman MM, Olfson M, Gameroff MJ, Feder A, Fuentes M (2001). A comparison of three scales for assessing social functioning in primary care. Am J Psychiatry 158:460–466.
Weissman MM, Markowitz JC, Klerman GL (2007). Clinician’s quick guide to interpersonal psychotherapy
. New York: Oxford University Press.
Weissman MM, Hankerson SH, Scorza P, Olfson M, Verdeli H, Shea S et al.
(2014). Interpersonal Counseling (IPC) for depression in primary care. Am J Psychotherapy 68:359–383.
Williams JBW, Kobak KA (2008). Development and reliability of a structured interview guide for the Montgomery-Asberg Depression Rating Scale (SIGMA). Br J Psychiatry 192:52–58.
Wittchen HU, Holsboer F, Jacobi F (2001). Met and unmet needs in the management of depressive disorder in the community and primary care: the size and breadth of the problem. J Clin Psychiatry 62:23–28.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]