Psychological Medicine

Original Articles

Efficacy of the sequential integration of psychotherapy and pharmacotherapy in major depressive disorder: a preliminary meta-analysis

J. Guidia1 c1, G. A. Favaa1a2, M. Favaa3a4 and G. I. Papakostasa3a4

a1 Affective Disorders Program, Department of Psychology, University of Bologna, Italy

a2 Department of Psychiatry, State University of New York at Buffalo, Buffalo, NY, USA

a3 Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA

a4 Department of Psychiatry, Harvard Medical School, Boston, MA, USA


Background Prevention of relapse and recurrence represents an important task in the successful treatment of major depressive disorder (MDD). The aim of this meta-analysis was to examine the efficacy of the sequential integration of psychotherapy and pharmacotherapy in reducing the risk of relapse and recurrence in MDD.

Method Keyword searches were conducted in Medline, EMBASE, PsycINFO and the Cochrane Library from inception of each database to December 2008. Randomized controlled trials examining the efficacy of the administration of psychotherapy after successful response to acute-phase pharmacotherapy in the treatment of adults with MDD were considered for inclusion in the meta-analysis.

Results Eight high-quality studies with 442 patients in a sequential treatment arm and 433 in a control treatment arm were included. The pooled risk ratio (RR) for relapse/recurrence was 0.797 [95% confidence interval (CI) 0.659–0.964] according to the random-effects model, suggesting a relative advantage in preventing relapse/recurrence for the sequential administration of treatments compared with control conditions. Performing subgroup analyses, we found a trend favoring psychotherapy during continuation of antidepressant drugs compared to antidepressants or treatment as usual (RR 0.842, 95% CI 0.674–1.051). Patients randomized to psychotherapy while antidepressants were discontinued were significantly less likely to experience relapse/recurrence compared to controls (RR 0.650, 95% CI 0.463–0.912).

Conclusions We found evidence that the sequential integration of psychotherapy and pharmacotherapy is a viable strategy for preventing relapse and recurrence in MDD. In addition, our findings suggest that discontinuation of antidepressant drugs may be feasible when psychotherapy is provided.

(Received August 21 2009)

(Revised December 07 2009)

(Accepted March 24 2010)

(Online publication May 06 2010)


c1 Address for correspondence: J. Guidi, Psy.D., Department of Psychology, University of Bologna, Viale Berti Pichat, 5, 40127 Bologna, Italy. (Email: