Psychological Medicine

Original Articles

Can pharmacotherapists be too supportive? A process study of active medication and placebo in the treatment of depression

D. R. Strunka1 c1, M. O. Stewarta2, S. D. Hollona2, R. J. DeRubeisa3, J. Fawcetta4, J. D. Amsterdama5 and R. C. Sheltona6

a1 Department of Psychology, Ohio State University, Columbus, OH, USA

a2 Department of Psychology, Vanderbilt University, Nashville, TN, USA

a3 Department of Psychology, University of Pennsylvania, Philadelphia, PA, USA

a4 Department of Psychiatry, University of New Mexico, Albuquerque, NM, USA

a5 Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA

a6 Department of Psychiatry, Vanderbilt University, Nashville, TN, USA


Background This study examined therapist–patient interactions during clinical management with antidepressant medication and pill-placebo.

Method The sample consisted of 80 patients on active medication and 40 patients in a pill-placebo condition from a randomized controlled trial for moderate to severe depression. Pharmacotherapist–patient interactions were characterized using observer ratings of the therapeutic alliance, pharmacotherapist-offered facilitative conditions, pharmacotherapist adherence to clinical management treatment guidelines and pharmacotherapist competence. Patients, therapists and raters were blind to treatment condition and outcome.

Results Provision of greater non-specific support (facilitative conditions) in early sessions predicted less subsequent improvement in depressive symptoms for patients receiving pill-placebo but not those receiving active medications, for which none of the process ratings predicted subsequent change. Early symptom change predicted later alliance and adherence in both conditions and therapist competence in the active condition.

Conclusions Higher levels of support in early sessions predict poorer subsequent response among placebo patients. It remains unclear whether patients who are likely to be refractory elicit greater non-specific support or whether the provision of such support has a deleterious effect in unmedicated patients. Differences in treatment process variables between conditions late in treatment are likely to be largely a consequence of symptom relief produced by active medications.

(Received December 30 2008)

(Revised September 10 2009)

(Accepted September 12 2009)

(Online publication November 06 2009)


c1 Address for correspondence: Dr D. R. Strunk, Department of Psychology, Ohio State University, 1835 Neil Avenue, Columbus, OH 43210, USA. (Email: