Benefits of Sequentially Adding Cognitive-Behavioral Therapy or Antidepressant Medication for Adults With Nonremitting Depression
Benefits of Sequentially Adding Cognitive-Behavioral Therapy or Antidepressant Medication for Adults With Nonremitting Depression
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DOI：
10.1176/appi.ajp.2018.18091075
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发表时间：
2019-04-01
影响因子：
17.7
通讯作者：
Craighead, W. Edward
中科院分区：
文献类型：
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作者：
Dunlop, Boadie W.;LoParo, Devon;Craighead, W. Edward
目的：成人重性抑郁症患者在初始治疗后往往不能达到缓解。对于使用抗抑郁药物赎罪未达到缓解的患者，增加心理治疗可以针对残留症状并防止复发，但在使用认知行为治疗（CBT）未缓解后增加抗抑郁药物的效用几乎没有研究。作者的目的是评估的急性和长期的结果，从两个序列的组合treatment.Methods：以前未经治疗的成年人与抑郁症谁被随机分配到接受艾司西酞普兰，度洛塞汀，或CBT单药治疗，并完成了12周的治疗没有达到缓解进入了额外的12周的联合治疗。对于CBT未达到缓解的患者，在治疗中添加艾司西酞普兰（CBT+药物组），对于抗抑郁药未达到缓解的患者，在治疗中添加CBT（药物+CBT组）。对联合治疗有反应的患者进入为期18个月的随访期，以评估复发风险。结果：共有112例未达到缓解的患者进入联合治疗（41例对单药治疗有反应，但未达到缓解，71例对单药治疗无反应）。总体而言，在后续联合治疗后，对单药治疗有反应但未达到缓解的患者（61%）的缓解率显著高于对单药治疗无反应的患者（41%）。在对单药治疗有反应但未达到缓解的患者中，CBT+药物组的缓解率（89%）高于药物+CBT组（53%）。然而，在单药治疗无应答的抑郁症患者中，两治疗组的应答率和缓解率相似。更高水平的焦虑，无论是在单药治疗和开始联合治疗之前，预测两个治疗groups.Conclusions：CBT和抗抑郁药物顺序相结合的结果较差。添加抗抑郁药是治疗CBT未达到缓解的患者残留症状的有效方法，抗抑郁药单药治疗后添加CBT也是如此。对一种治疗方式无反应的患者需要考虑添加替代方式。
Objective: Adults with major depressive disorder frequently do not achieve remission with an initial treatment. Addition of psychotherapy for patients who do not achieve remission with antidepressant medication atone can target residual symptoms and protect against recurrence, but the utility of adding antidepressant medication after nonremission with cognitive-behavioral therapy (CBT) has received little study. The authors aimed to evaluate the acute and long-term outcomes resulting from both sequences of combination treatments.Methods: Previously untreated adults with major depression who were randomly assigned to receive escitalopram, duloxetine, or CBT monotherapy and completed 12 weeks of treatment without achieving remission entered an additional 12 weeks of combination treatment. For patients who did not achieve remission with CBT, escitalopram was added (CBT plus medication group) to their treatment, and for those who did not achieve remission with an antidepressant, CBT was added (medication plus CBT group) to their treatment. Patients who responded to the combination treatment entered an 18 -month follow-up phase to assess risk of recurrence.Results: A total of 112 patients who did not achieve remission with a monotherapy entered combination treatment (41 who responded to monotherapy but did not achieve remission and 71 who did not respond to monotherapy). Overall, remission rates after subsequent combination therapy were significantly higher among patients who responded to monotherapy but did not achieve remission (61%) than among patients who did not respond to monotherapy (41%). Among patients who responded to monotherapy but did not achieve remission, the remission rate in the CBT plus medication group (89%) was higher than in the medication plus CBT group (53%). However, among patients whose depression did not respond to monotherapy, rates of response and remission were similar between the treatment arms. Higher levels of anxiety, both prior to monotherapy and prior to beginning combination treatment, predicted poorer outcomes for both treatment groups.Conclusions: The order in which CBT and antidepressant medication were sequentially combined did not appear to affect outcomes. Addition of an antidepressant is an effective approach to treating residual symptoms for patients who do not achieve remission with CBT, as is adding CBT after antidepressant monotherapy. Patients who do not respond to one treatment modality warrant consideration for addition of the alternative modality.