Many people struggling with moderate to severe depression face a variety of treatment options. The goal of any type of treatment is to achieve a remission of symptoms that will help patients engage fully with meaningful aspects of their lives, without interference from their symptoms.
Research suggests that the combination of depression-focused psychotherapy, such as behavioral activation or interpersonal psychotherapy1, with SSRIs or other antidepressant medication offers the most promising results.2 Given that combined treatment is recommended, mental health professionals raise many questions about how best to deliver both forms of treatment to clients who lead busy lives.
Two Types of Treatment: Integrated and Split
Some individuals may see a psychiatrist who can prescribe medication and deliver psychotherapy. This is defined as integrated treatment3,4. Others may see a psychiatrist who only prescribes medication, and then also see a psychologist or mental health counselor who provides psychotherapy only. This is defined as split treatment.
There is little research on which treatment type people prefer and which leads to the best outcomes. Some people may prefer the simplicity of one provider through integrated treatment. Others may prefer separate providers who have expertise in each treatment modality.
Which Works Best?
A team of researchers at Fordham University examined the two types of treatment delivery. They tested whether clients reported more satisfaction and better treatment adherence from split treatment or integrated treatment for depression5. Participants in this study were 120 adults, who self-reported moderate to severe symptoms of depression and were receiving either integrated or split treatment. They were mostly white, employed, and had completed at least some college.
You Can Get Some Satisfaction
The researchers compared differences in satisfaction and treatment adherence from split and integrated treatments. They found no differences in satisfaction, suggesting that clients are generally equally satisfied and they adhere to both split and integrated treatment.
However, they also wanted to know what predicts satisfaction and adherence for both types. They examined preference strength for the type of treatment, attachment style (the ways that people relate to others), and the therapeutic alliance (the relationship between the mental health care professional and the patient).
Results Reveal More Key Findings
The researchers found that the strength of preference and the alliance predicted satisfaction with both types of treatment, regardless of which a client was receiving. This suggests that clients will be more satisfied with treatment if it lines up with their specific preferences.
It also suggests other key results:
- Clients and their therapists and physicians should have open conversations about treatment preferences to inform their treatment selection.
- Psychiatry and psychotherapy providers should be invested in cultivating a strong therapeutic alliance with their clients to enhance satisfaction.
- Clients may want to find a different provider if they find it difficult to develop a positive working alliance; this challenge may affects their satisfaction with treatment.
In addition, clients with stronger, secure personal attachments were more likely to adhere to taking their psychiatric medication, compared to those with less secure attachments. This suggests that the latter are more at risk of not adhering to their medication, regardless of the form of treatment they are receiving. It is important for providers to understand a client's attachment style to inform how they prescribe and monitor medication, and to work with clients to troubleshoot difficulties.
Factors for Future Studies
This study is an important first examination into how different forms of depression-treatment delivery affect satisfaction and adherence. However, it does not examine symptom change, functional impairment, or quality of life. An important next step will be to see if split or integrated treatment result in different outcomes for clients.
In addition, this study did not examine specific types of medication or psychotherapy delivery within each group. There are many different medications and psychotherapies to treat depression, so more in-depth follow-up studies that compare specific evidence-based treatments in split or integrated delivery formats will be important. This was a cross-sectional survey study (i.e., it examined the participants at a specific time), so any causal relationships between the therapeutic alliance, preferences, and satisfaction and adherence cannot be established. Because the participants were mostly white, the findings do not apply to racially and ethnically diverse communities. These questions should be investigated further in more diverse populations.
Finally, there are many scenarios in which clients experiencing moderate to severe depression do not want to or cannot take psychiatric medications due to pregnancy or other health conditions. This study reinforces that the idea of honoring patient preferences in these circumstances is incredibly important because it may affect treatment adherence and satisfaction.
1. Cuijpers, P., van Straten, A., Andersson, G., & van Oppen, P. (2008). Psychotherapy for depression in adults: A meta-analysis of comparative outcome studies. Journal of Consulting and Clinical Psychology, 76(6), 909-922. doi:10.1037/a0013075
2. American Psychiatric Association (APA). (2010). Practice Guideline for the Treatment of Patients With Major Depressive Disorder (3rd ed.). Washington, DC: Author.
3. Kay, J. (2001). Integrated treatment. Integrated Treatment of Psychiatric Disorders, 20, 1.
4. Riba, M., & Balon, R. (2011). Combining psychotherapy and pharmacotherapy. In R. Hales, S. Yudofsky, & G. O. Gabbard (Eds.), The American Psychiatric Publishing Textbook of clinical psychiatry (5th ed.). Washington, DC: American Psychiatric Publishing, Inc.
5. Baruch, R. L., & Annunziato, R. A. (2017). Outcomes of Combined Treatment: Evaluating Split Versus Integrated Treatment for Depression. Professional Psychology: Research and Practice, doi:10.1037/pro0000144.