Diagnostic Indications and Contraindications

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.

Combined Medication and Psychotherapy Diagnostic Indications and Contraindications Other Indications and Contraindications Evidence for Acute-Phase Efficacy