Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma

Abstract

Major depressive disorder is associated with considerable morbidity, disability, and risk for suicide. Treatments for depression most commonly include antidepressants, psychotherapy, or the combination. Little is known about predictors of treatment response for depression. In this study, 681 patients with chronic forms of major depression were treated with an antidepressant (nefazodone), Cognitive Behavioral Analysis System of Psychotherapy (CBASP), or the combination. Overall, the effects of the antidepressant alone and psychotherapy alone were equal and significantly less effective than combination treatment. Among those with a history of early childhood trauma (loss of parents at an early age, physical or sexual abuse, or neglect), psychotherapy alone was superior to antidepressant monotherapy. Moreover, the combination of psychotherapy and pharmacotherapy was only marginally superior to psychotherapy alone among the childhood abuse cohort. Our results suggest that psychotherapy may be an essential element in the treatment of patients with chronic forms of major depression and a history of childhood trauma.

Figures

Fig. 1.

(A) Response to antidepressant (nefazodone), psychotherapy (CBASP), and the combination (nefazodone and CBASP) as a function of treatment type and early adverse life events in patients with chronic forms of major depression. In this completer analysis, the effect of the presence or absence of histories of childhood adversity (parental loss, physical abuse, sexual abuse, neglect) on HRSD24 scores was evaluated. A general linear model with two factors (treatment and childhood adverse experience) was computed. *, There was a significant interaction of effects of treatment type and parental loss (F = 4.46, df = 1,495, P = 0.0121), physical abuse (F = 3.25, df = 1,495, P = 0.03), neglect (F = 4.82, df = 1,495, P = 0.0084), and any trauma (F = 3.13, df = 1,495, P = 0.0446). The patients with any early life trauma responded well to psychotherapy alone or the combined treatment but not to antidepressant alone. Patients with chronic depression with early life trauma responded equally well to antidepressant and CBASP. (B) Remission rates as a function of treatment type and early adverse life events in patients with chronic forms of major depression. Remission was defined as HRSD24 score ≥8. *, Completer analysis using logistic modeling revealed a significantly higher remission rate in the patients with chronic forms of major depression and early life trauma treated with psychotherapy compared to antidepressant treatment (Wald χ2 = 6.8912, df = 1, P = 0.0087). The effect was confirmed in the LOCF analysis (Wald χ2 = 6.5315, df = 1, P = 0.0106). The likelihood of achieving remission in patients with chronic forms of major depression and any early adverse life event was twice as high after treatment with psychotherapy when compared to antidepressant therapy (odds ratio = 2.322, 95% confidence interval = 1.225-4.066). Further analysis of type of early trauma indicates that this effect was particularly prominent in patients with chronic forms of depression and parental loss (odds ratio for remission after psychotherapy versus antidepressant = 2.7857, 95% confidence interval = 1.295-6.182).