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CBT and Antidepressants: Does Sequence Matter?

Am J Psychiatry; ePub 2019 Feb 15; Dunlop, et al

The order in which cognitive-behavioral therapy (CBT) and antidepressant medication were sequentially combined did not appear to affect patient outcomes, according to a recent study. The addition of an antidepressant, however, is an effective approach to treating residual symptoms for patients who do not achieve remission with CBT, as is adding CBT after antidepressant monotherapy. 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). Researchers found:

  • 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.

Dunlop BW, LoParo D, Kinkead B, et al. Benefits of sequentially adding cognitive-behavioral therapy or antidepressant medication for adults with nonremitting depression. [Published online ahead of print February 15, 2019]. Am J Psychiatry. doi:10.1176/appi.ajp.2018.18091075.


This study contributes to existing literature regarding the combining of medications and psychotherapy in the treatment of major depressive disorder (MDD). In clinical practice, many clinicians anecdotally believe that if therapy fails, then an antidepressant is warranted. Less often, prescribers will aim to move in the reverse direction when an antidepressant fails and are less likely to consider psychotherapy. This investigation provides answers to this clinical dilemma when the specific psychotherapy being utilized is cognitive behavioral therapy (CBT). For patients who are partial responders (not remitters), adding a medication post-CBT failure is optimal. However, patients tended to improve when a novel treatment was combined, suggesting that the key to successful remission in MDD is to continue modifying treatments of different modalities until remission occurs.—Thomas L. Schwartz, MD; Senior Associate Dean of Education, Interim Chair/Professor of Psychiatry, SUNY Upstate Medical University.