Sequential Use of Pharmacotherapy and Psychotherapy in Mood Disorders

Chiara Rafanelli, Giovanni A Fava
European Psychiatric Review, 2011;4(1):21-24
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Abstract

In the past decade, several investigations have suggested the usefulness of a sequential way of integrating pharmacotherapy and psychotherapy in mood disorders. The aims of this article were: a) to introduce the clinical rationale for integrating treatments in a sequential order; b) to update the literature on clinical trials where pharmacotherapy followed by psychotherapy was used in a sequential order, both in unipolar depression and bipolar disorder; c) to examine the implications of this approach for psychiatric practice with special reference to assessment.
Keywords
Mood disorder, subclinical symptoms, staging, sequential model, pharmacotherapy, psychotherapy, cognitive behavioural therapy
Disclosure The authors have no conflicts of interest to declare.
Received: March 05, 2010 Accepted October 13, 2010
Correspondence: Giovanni A Fava, Department of Psychology, University of Bologna, Viale Berti Pichat 5, 40127 Bologna, Italy. E: giovanniandrea.fava@unibo.it
Clinical Rationale for Integrating Treatments in a Sequential Order

In the past decade, in clinical psychiatry, several investigations have suggested the usefulness of a sequential way of integrating pharmacotherapy and psychotherapy in mood disorders,1,2 where psychotherapy is employed to improve symptoms which pharmacotherapy is unable to affect. The largest depression trial, the Sequenced treatment alternatives to relieve depression (STAR*D) study, found evidence potentially supporting the need for treatments, aimed at different effects in affective disorders.3

The STAR*D study has provided a dramatic illustration of the difficulties in getting recovery from depressive illness by using pharmacological strategies alone.3 The cumulative rate of remission (scoring seven or less on the Hamilton Rating Scale of Depression, HAM-D17) after four sequential steps was 67%.3 However, taking into account relapse rates while on treatment, the cumulative rate was 43%.4 This means that the efforts after step one (open treatment with citalopram) yielded an additional 6% of sustained recovery compared with the initial 37%.5 Unfortunately, because of the type of randomisation that was chosen in STAR*D (equipoise-stratified randomisation strategy), the role of cognitive therapy (that was one of the strategies offered after step one) could not be established, since the people who opted for it were too few (less than one-third of participants).6

The phenomenological development of a mood disorder such as unipolar depression may be categorised according to stages (see Table 1).5,7–9 Staging has the potential to improve the logic and timing of interventions in psychiatry.8 For example, a treatment that may be effective in stage 2 major depressive episode (previously untreated) may not be as effective at stage 4 of a recurrent major depression. Treatments that are administered in a sequential order (psychotherapy after pharmacotherapy, psychotherapy followed by pharmacotherapy, one drug treatment following another or one psychotherapeutic treatment following another) may be more successful in eliminating residual symptomatology than introducing all treatments at the same time. Residual symptoms upon recovery may in fact progress to become prodromal symptoms of relapse, and treatment of residual symptoms may yield long-term benefits.10 Increasing the level of remission is an important task and challenge of psychiatry.5

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