Combined Medication and Psychotherapy: Diagnostic Indications and Contraindications
At this time, there are few indications for combined treatment that have been established on an empirical basis, but some patterns are suggestive (Rush and Thase 1999). Unipolar depression can be treated with either drugs or psychotherapy alone, whereas medications are almost always involved in the treatment of bipolar disorder, but in neither case can polarity be considered an indication for (or against) combined treatment. Virtually all of the existing controlled trials involving combined treatment have been conducted with unipolar patients, but some interesting work with bipolar patients is currently under way (Basco and Rush 1996). Either pharmacotherapy or electroconvulsive therapy would clearly be the treatment of choice for patients with psychotic mood disorders; it remains unknown if adding psychotherapy (usually after some initial remission in the acute psychosis) does anything to enhance response for such patients. Endogenicity (or “melancholia”) tends to predict superior response to drugs relative to placebo even among nonpsychotic patients with unipolar depression. However, it is not clear that such patients require medication, because they also appear to do quite well in at least some forms of psychotherapy.

DSM-IV (American Psychiatric Association 1994) distinguishes between major depressive and dysthymic disorders, with the former defined largely on the basis of severity and the latter defined largely on the basis of chronicity. It is quite possible for patients with chronic depressions to also have episodes of sufficient severity to meet the criteria for major depression. In fact, despite the earlier belief that depressions were either severe and episodic or mild and chronic, there is considerable evidence that persons with chronic dysthymic disorders are at particular risk for major depressive episodes.

Similarly, although it was once believed that as many as half of all depressions would be limited to a single episode only, more recent studies suggest that up to 90% of all persons with mood disorders will experience multiple episodes (Consensus Development Panel 1985). Severity clearly predicts superior response to medication relative to placebo, but it is less clear that severity predicts differential response to medication versus psychotherapy, at least among outpatients with nonpsychotic unipolar depressions (Munoz et al. 1994). Several studies have failed to find any advantage for drugs over psychotherapy among more severely depressed patients, but a recent mega-analysis (meta-analysis of original data) found evidence that combined treatment was superior to psychotherapy alone among more severely depressed outpatients (Thase et al. 1997). Patients with chronic depression tend to do less well with either drugs or psychotherapy than patients with less chronic depression and may be among those most in need of combined treatment. As previously noted, a recent multisite study found that the combination of drugs and psychotherapy was particularly effective in the treatment of such patients, producing greater rates of both response and remission.

Mood disorders (particularly depression) are also commonly found in conjunction with other psychiatric or general medical disorders. Whether the mood disorder should be treated first (or even at all) depends on the nature of the other disorder and the specific clinical picture. The AHCPR guidelines provide an excellent discussion of factors that need to be considered in such instances (Depression Guideline Panel 1993). In general, when two (or more) psychiatric disorders are present, choosing a treatment regimen that has demonstrable efficacy for both (or all) components is to be preferred; there may be instances in which combined treatment comes closer to satisfying this guideline than does either modality alone. Medical illnesses with clear somatic bases are more likely to be treated first before intensive psychopharmacological or psychotherapeutic regimens are implemented.