Abstract
The sequential model of treatment for depression, i.e. the use of psychotherapy in patients who have remitted from a major depressive disorder after a course of pharmacotherapy, is an intensive two-stage approach that derives from the awareness that one course of treatment is unlikely to provide a solution to all the symptoms of patients. The aim of the sequential approach is to provide different types of treatment for as long as considered necessary in different phases of illness as determined by repeated assessments. The treatment strategies are chosen on the basis of the symptoms identified and not as predefined options. The sequential model emphasizes consideration of subclinical and residual symptomatology according to the organizing principles of macro-analysis (a relationship between co-occurring symptoms and problems is established on the basis of where treatment should commence in the first place). Diagnostic endpoints (i.e. DSM diagnoses), the customary guidance of treatment planning, are replaced by conceptualization of disorders as ‘transfer stations’, which are amenable to longitudinal verification and modification.
The aim of this systematic review was to survey the literature concerned with the sequential approach to the treatment of depression. Randomized controlled trials were identified using MEDLINE and a manual search of the literature. In seven of the eight studies that were identified, the sequential use of pharmacotherapy and psychotherapy was found to improve long-term outcome after termination of treatment compared with clinical management and treatment as usual. Nevertheless, data on this approach are limited and more studies are necessary for detailing the various clinical steps associated with it.
The sequential approach calls for a re-assessment of the design of comparative clinical trials. It allows randomization of patients who are already in treatment and assignment of them to treatment alternatives according to stages of development of their illness and not simply to disease classification. The model is thus more in line with the chronicity of mood disorders compared to the standard randomized controlled trial, which is based on the acute disease model.
Similar content being viewed by others
References
Uhlenhuth EH, Lipman RS, Covi L. Combined pharmacotherapy and psychotherapy. J Nerv Ment Dis 1969; 148: 52–64
Thase ME, Jindal RD. Combining psychotherapy and psychopharmacology for treatment of mental disorders. In: Lambert MJ, editor. Bergin and Garfield’s handbook of psychotherapy and behavior change. New York: Wiley, 2004: 743–66
Otto MW, Smits JAJ, Reese HE. Combined psychotherapy and pharmacotherapy for mood and anxiety disorders in adults. Clin Psychol Sci Prac 2005; 12: 72–86
Hollon SD, Jarrett RB, Nierenberg AA, et al. Psychotherapy and medication in the treatment of adult and geriatric depression: which monotherapy or combined treatment? J Clin Psychiatry 2005; 66: 455–68
Friedman ES, Thase ME. Combining cognitive-behavioral therapy with medication. In: Gabbard GO, editor. Textbook of psychotherapeutic treatments. Washington, DC: American Psychiatric Press, 2009: 263–85
Hellerstein DJ. Combining supportive psychotherapy with medication. In: Gabbard GO, editor. Textbook of psychotherapeutic treatments. Washington, DC: American Psychiatric Press, 2009: 465–96
Vesga-Lopez O, Blanco C. Combining interpersonal psychotherapy with medication. In: Gabbard GO, editor. Textbook of psychotherapeutic treatments. Washington, DC: American Psychiatric Press, 2009: 365–89
Marks IM, Swinson RP, Basoglu M, et al. Alprazolam and exposure alone and combined in panic disorder with agoraphobia. Br J Psychiatry 1993; 162: 776–87
Barlow DH, Gorman JM, Shear MK, et al. Cognitive behavioral therapy, imipramine and their combination for panic disorder. JAMA 2000; 283: 2529–36
Haug TT, Blomhoff S, Hellstrom K, et al. Exposure therapy and sertraline in social phobia. Br J Psychiatry 2003; 182: 312–8
Otto MW, Basden SL, McHugh RK, et al. Effects of D-cycloserine administration on weekly nonemotional memory tasks in healthy participants. Psychother Psychosom 2009; 78: 49–54
Norberg MH, Krystal JH, Tolin DF. A meta-analysis of D-cycloserine and the facilitation of fear extinction and exposure therapy. Biol Psychiatry 2008; 63: 118–26
Bandelow B, Seidler-Brandler U, Becker A, et al. Metaanalysis of randomized controlled comparisons of psychopharmacological and psychological treatments for anxiety disorders. World J Biol Psychiatry 2007; 8: 175–87
Hofmann SG, Smits JAJ. Cognitive-behavioral therapy for adult anxiety disorders. J Clin Psychiatry 2008; 69: 621–32
Imel ZE, Malterer MB, McKay KM, et al. A meta-analysis of psychotherapy and medication in unipolar depression and dysthymia. J Affect Disord 2008; 110: 197–206
Vittengl JR, Clark LA, Dunn TW, et al. Reducing relapse and recurrence in unipolar depression. J Consul Clin Psychol 2007; 75: 475–88
Butler C, Chapman JE, Forman EM, et al. The empirical status of cognitive-behavioral therapy. Clin Psychol Rev 2006; 26: 17–31
Keller MB, McCullough JP, Klein DN, et al. A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. N Engl J Med 2000; 342: 1462–70
Feinstein AR, Horwitz RI. Problems in the ‘evidence’ of ‘evidence-based medicine’. Am J Med 1997; 103: 529–35
Fava GA. The decline of pharmaceutical psychiatry and the increasing role of psychological medicine. Psychother Psychosom 2009; 78: 220–7
Reus VI, Weingartner H, Post RM. Clinical implications of state-dependent learning. Am J Psychiatry 1979; 136: 927–31
Scott J, Paykel E, Morriss R, et al. Cognitive-behavioral therapy for severe and recurrent bipolar disorders. Br J Psychiatry 2006; 188: 313–20
Fava GA, Bartolucci G, Rafanelli C, et al. Cognitive behavioral management of patients with bipolar disorder relapsing while on lithium prophylaxis. J Clin Psychiatry 2001; 62: 556–9
Scott J, Garland A, Moorhead S. A pilot study of cognitive therapy in bipolar disorder. Psychol Med 2001; 31: 459–67
Lam DH, Watkins ER, Hayward P, et al. A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder. Arch Gen Psychiatry 2003; 60: 145–52
Colom F, Vieta E, Martinez-Aran A, et al. A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Arch Gen Psychiatry 2003; 60: 402–7
Colom F, Vieta E, Reinares M, et al. Psychoeducation efficacy in bipolar disorder: beyond compliance enhancement. J Clin Psychiatry 2003; 64: 1101–5
Miklowitz DJ, Otto MW, Frank E, et al. Intense psychosocial intervention enhances functioning in patients with bipolar depression. Am J Psychiatry 2007; 164: 1340–7
Lorr M, McNair DM, Weinstein GJ. Early effects of chlordiazepoxide (Librium) used with psychotherapy. J Psychiat Res 1963; 1: 257–70
Rickels K, Cattell RB, Weise C, et al. Controlled psychopharmacological research in private psychiatric practice. Psychopharmacologia 1966; 9: 288–306
Bech P. Fifty years with the Hamilton scales for anxiety and depression. Psychother Psychosom 2009; 78: 202–11
Stewart JW, Mercier MA, Agosti V, et al. Imipramine is effective after unsuccessful cognitive therapy. J Clin Psychopharmacology 1993; 13: 114–9
Schatzberg AF, Rush AJ, Arnow BA, et al. Chronic depression: medication (nefazodone) or psychotherapy (CBASP) is effective when the other is not. Arch Gen Psychiatry 2005; 62: 513–20
Swan J, Sorrell E, MacVicar B, et al. “Coping with depression”. J Affect Disord 2004; 82: 125–9
Fava GA, Savron G, Zielezny M, et al. Overcoming resistance to exposure in panic disorder with agoraphobia. Acta Psychiat Scand 1997; 95: 306–12
Kampman M, Keijser GPJ, Hoogduin CAL, et al. A randomized, double-blind placebo controlled study on the effects of adjunctive paroxetine in panic disorder patients unsuccessfully treated with cognitive behavioral treatment alone. J Clin Psychiatry 2002; 63: 772–7
Heldt E, Blaya C, Isolan L, et al. Quality of life and treatment outcome in panic disorder. Psychother Psychosom 2006; 75: 183–6
Fava GA, Savron G, Grandi S, et al. Cognitive behavioral management of drug-resistant major depressive disorder. J Clin Psychiatry 1997; 58: 278–82
Thase ME, Friedman ES, Biggs MM, et al. Cognitive therapy versus medication in augmentation and switch strategies as second-steps treatments. Am J Psychiatry 2007; 64: 739–52
Eisendrath SJ, Delucchi K, Bitner R, et al. Mindfulness-based cognitive therapy for treatment resistant depression. Psychother Psychosom 2008; 77: 319–20
Tolin DF, Malthy N, Diefenbach GJ, et al. Cognitive behavioral therapy for medication nonresponders with obsessive-compulsive disorder. J Clin Psychiatry 2004; 65: 922–31
Kuyken W, Tsivrikos D. Therapist competence, comorbidity and cognitive behavioral therapy for depression. Psychother Psychosom 2009; 78: 42–8
Fava GA, Ruini C, Rafanelli C. Sequential treatment of mood and anxiety disorders. J Clin Psychiatry 2005; 66: 1392–400
Bear HD, Anderson S, Brown A, et al. The effect on tumor response of adding sequential preoperative docetaxel to preoperative doxorubicin and cyclophosphamide. J Clin Oncology 2003; 21: 4165–74
Robbins GK, De Gruttola V, Shafer RN, et al. Comparison of sequential three-drug regimen as initial therapy for HIV-1 infection. N Engl J Med 2003; 349: 2293–303
Hasan F, al-Khaldi J, Asker H, et al. Treatment of chronic hepatitis B with sequential administration of interferon and lamivudine. Hepatogastroenterology 2003; 50(54): 2040–2
Lebwohl M, Menter A, Koo J, et al. Combination therapy to treat moderate to severe psoriasis. J Am Acad Dermatol 2004; 50: 416–30
Holzgreve H. Combination versus monotherapy as initial treatment in hypertension. Herz 2003; 28: 725–32
Belami CP, Wany W, Johnson DH, et al. Phase III study of the Eastern Cooperative Oncology Group (ECOG2597). J Clin Oncol 2005; 23: 3760–7
Vakil N, Vaira D. Sequential therapy for Helicobacter pylori. JAMA 2008; 300: 1346–7
Fava GA, Ruini C, Belaise C. The concept of recovery in major depression. Psychol Med 2007; 37: 307–17
Paykel ES. Achieving gains beyond response. Acta Psychiatr Scand 2002; 106: 12–7
Fava GA, Kellner R. Prodromal symptoms in affective disorder. Am J Psychiatry 1991; 148: 823–30
Fava GA, Kellner R. Staging: a neglected dimension in psychiatric classification. Acta Psychiatr Scand 1993; 87: 225–30
Fava GA, Tomba E, Grandi S. The road to recovery from depression. Psychother Psychosom 2007; 76: 260–5
Goldapple K, Segal Z, Garson C, et al. Modulation of cortical-limbic pathways in major depression. Arch Gen Psychiatry 2004; 61: 34–41
Maj M. The aftermath of the concept of psychiatric comorbidity. Psychother Psychosom 2005; 74: 65–7
Zimmerman M, Chelminski I, McDermut W. Major depressive disorder and axis I diagnostic comorbidity. J Clin Psychiatry 2002; 63: 187–93
Sherbourne CD, Wells KB. Course of depression in patients with comorbid anxiety disorders. J Affect Disord 1997; 43: 245–50
Gaynes BN, Magruder KM, Burns BJ, et al. Does a coexisting anxiety disorder predict persistence of depressive illness in primary care patients with major depression? Gen Hosp Psychiatry 1999; 21: 158–67
Fava GA, Grandi S, Zielezny M, et al. Cognitive behavioral treatment of residual symptoms in primary major depressive disorders. Am J Psychiatry 1994; 151: 1295–9
Fava GA, Grandi S, Zielezny M, et al. Four year outcome for cognitive behavioral treatment of residual symptoms in major depression. Am J Psychiatry 1996; 153: 945–7
Fava GA, Rafanelli C, Grandi S, et al. Six year outcome for cognitive behavioral treatment of residual symptoms in major depression. Am J Psychiatry 1998; 155: 1443–5
Frank E, Kupfer DJ, Perel JM, et al. Three year outcomes for maintenance therapies in recurrent depression. Arch Gen Psychiatry 1990; 47: 1093–9
Fava GA, Rafanelli C, Grandi S, et al. Prevention of recurrent depression with cognitive behavioral therapy. Arch Gen Psychiatry 1998; 55: 816–20
Fava GA, Ruini C, Rafanelli C, et al. Six-year outcome of cognitive behavior therapy for prevention of recurrent depression. Am J Psychiatry 2004; 161: 1872–6
Paykel ES, Scott J, Teasdale JD, et al. Prevention of relapse in residual depression by cognitive therapy. Arch Gen Psychiatry 1999; 56: 829–35
Scott J, Teasdale JD, Paykel ES, et al. Effects of cognitive therapy on psychological symptoms and social functioning in residual depression. Br J Psychiatry 2000; 170: 440–6
Scott J, Palmer S, Paykel ES, et al. Use of cognitive therapy for relapse prevention in chronic depression: cost effectiveness study. Br J Psychiatry 2003; 182: 221–7
Paykel ES, Scott J, Cornwall PL, et al. Duration of relapse prevention after cognitive therapy in residual depression: follow-up of controlled trial. Psychol Med 2005; 35: 59–68
Teasdale JD, Segal ZV, Williams JMG, et al. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. J Consult Clin Psychol 2000; 68: 615–23
Perlis RH, Nierenberg AA, Alpert JE, et al. Effects of adding cognitive therapy to fluoxetine dose increase on risk of relapse and residual depressive symptoms in continuation treatment of major depressive disorder. J Clin Psychopharmacol 2002; 22: 474–80
Petersen T, Harly R, Papakostas G, et al. Continuation cognitive behavioral therapy maintains attributional style improvement in depressed patients responding acutely to fluoxetine. Psychol Med 2004; 34: 555–61
Ma SH, Teasdale JD. Mindfulness-based cognitive therapy for depression. J Consult Clin Psychol 2004; 72: 31–40
Bockting CLH, Schene AH, Spinhoven P, et al. Preventing relapse/recurrence in recurrent depression using cognitive therapy. J Consult Clin Psychol 2005; 73: 647–52
Bockting CLH, Spinhoven P, Koeter MWJ, et al. Differential predictors of response to preventive cognitive therapy in recurrent depression. Psychother Psychosom 2006; 75: 229–36
Bockting CLH, ten Doesschate MC, Spijker J, et al., the Delta Study Group. Combination and maintenance of antidepressants in recurrent depression. Psychother Psychosom 2008; 77: 17–26
Kuyken W, Byford S, Taylor RS, et al. Mindfulness-based cognitive therapy to prevent relapse in recurrent depression. J Consult Clin Psychol 2008; 76: 966–78
Fava GA, Ruini C, Rafanelli C, et al. Cognitive behavior approach to loss of clinical effect during long-term antidepressant treatment. Am J Psychiatry 2002; 159: 2094–5
Fabbri S, Fava GA, Rafanelli C, et al. Family intervention approach to loss of clinical effect during long-term antidepressant treatment. J Clin Psychiatry 2007; 68: 1348–51
Mohr DC, Spring B, Freedland KE, et al. The selection and design of control conditions for randomized controlled trials of psychological interventions. Psychother Psychosom 2009; 78: 275–84
Balon R. Cognitive-behavioral therapy, psychotherapy and psychosocial interventions in the medically ill. Psychother Psychosom 2009; 78: 261–4
Judd LJ, Paulus MJ, Schettler PJ, et al. Does incomplete recovery from first lifetime major depressive episode herald a chronic course of illness? Am J Psychiatry 2000; 157: 1501–4
Fava GA, Runi C, Sonino N. Treatment of recurrent depression. CNS Drugs 2003; 17: 1109–17
Rafanelli C, Fava GA, Sonino N. Sequential treatment of depression in primary care. Int J Clin Pract 2007; 61: 1719–29
Fava GA, Ruini C. Development and characteristics of a well-being enhancing psychotherapeutic strategy: well-being therapy. J Behav Ther Exp Psychiatry 2003; 34: 45–63
Fava GA, Tomba E. Increasing psychological well-being and resilience by psychotherapeutic methods. J Pers 2009; 77: 1903–34
Blackburn IM, Moore RG. Controlled acute and follow-up trial of cognitive therapy in outpatients with recurrent depression. Br J Psychiatry 1997; 171: 328–34
Hollon SD, de Rubeis RJ, Shelton RC, et al. Prevention of relapse following cognitive therapy vs medications in moderate to severe depression. Arch Gen Psychiatry 2005; 62: 417–22
Hetrick SE, Parker AG, Hickie IB, et al. Early identification and intervention in depressive disorders: towards a clinical staging model. Psychother Psychosom 2008; 77: 263–70
Fava GA, Rafanelli C, Tossani E, et al. Agoraphobia is a disease: a tribute to Sir Martin Roth. Psychother Psychosom 2008; 77: 133–8
Feinstein AR. The Jones criteria and the challenge of clinimetrics. Circulation 1982; 66: 1–5
Fava GA, Ruini C, Rafanelli C. Psychometric theory is an obstacle to the progress of clinical research. Psychother Psychosom 2004; 73: 145–8
Bech P. Modern psychometrics in clinimetrics. Psychother Psychosom 2004; 73: 134–8
Faravelli C. Assessment of psychopathology. Psychother Psychosom 2004; 73: 139–41
Emmelkamp PMG, Bouman TK, Scholing A. Anxiety disorders. Chichester: Wiley, 1993
Emmelkamp PMG, Bouman TK, Blauuw E. Individualized versus standardized therapy. Clin Psychol Psychother 1994; 1: 95–100
Vedel E, Emmelkamp PMG. Behavioral couple therapy in the treatment of female alcohol-dependent patient with comorbid depression, anxiety and personality disorders. Clin Case Studies 2004; 3: 187–205
Emmelkamp PMG. The additional value of clinimetrics needs to be established rather than assumed. Psychother Psychosom 2004; 73: 142–4
Fava GA, Sonino N. Psychosomatic assessment. Psychother Psychosom 2009; 78: 333–41
Sonino N, Peruzzi P. A psychoneuroendocrinology service. Psychother Psychosom 2009; 78: 346–51
Feinstein AR. An analysis of diagnostic reasoning: I. The domains and disorders of clinical macrobiology. Yale J Biol Med 1973; 46: 212–32
Tinetti ME, Fried T. The end of the disease era. Am J Med 2004; 116: 179–85
Chouinard G, Chouinard VA. Atypical antipsychotics. Psychother Psychosom 2008; 77: 69–77
Fountoulakis KN, Gonda X, Siamouli M, et al. Psychotherapeutic intervention and suicide reduction in bipolar disoder. J Affect Disord 2009; 113: 21–9
Bilsker D, Wiseman S, Gilbert M. Managing depression-related occupational disability. Can J Psychiatry 2006; 51: 76–83
Kennedy N, Foy K, Sherazi R, et al. Long-term social functioning after depression treated by psychiatrists. Bipolar Disord 2007; 9: 25–37
Watkins E, Scott J, Wingrove J, et al. Rumination-focused cognitive behavioral therapy for residual depression. Behav Res Ther 2007; 45: 2144–54
Kingston T, Dooley B, Bates A, et al. Mindfulness-based cognitive therapy for residual depressive symptoms. Psychol Psychother 2007; 80: 193–203
Menza M, Marin H, Sokol Opper R. Residual symptoms in depression: can treatment be symptom-specific? J Clin Psychiatr 2003; 64: 516–23
Fava GA, Molnar G, Spinks H, et al. Health attitudes and psychological distress in patients attending a lithium clinic. Acta Psychiatr Scand 1984; 70: 591–3
Chuang HT, Mansell C, Patten SB. Lifestyle characteristics of psychiatric outpatients. Can J Psychiatry 2008; 53: 260–6
Sirri L, Grandi S, Fava GA. The Illness Attitude Scales: a clinimetric index for assessing hypochondriacal fears and beliefs. Psychother Psychosom 2008; 77: 337–50
Dobkin PL, Filipski H, Looper K, et al. Identifying target areas of treatment for depressed early inflammatory arthritis patients. Psychother Psychosom 2008; 77: 298–305
Moncrieff J, Cohen D. Rethinking models of psychotropic drug action. Psychother Psychosom 2005; 74: 145–53
Fava GA, Park SK, Dubovsky SL. The mental health clinic: a new model. World Psychiatry 2008; 7: 177–81
Layard R. The case for psychological treatment centres. BMJ 2006; 332: 1030–2
Marks I. Mental health clinics in the 21st century. Psychother Psychosom 2009; 78: 133–8
Kupfer DJ. Maintenance treatment in recurrent depression. Br J Psychiatry 1992; 161: 309–16
Lavori PW, Dawson R. Adaptive treatment strategies in chronic disease. Annu Rev Med 2008; 59: 443–53
Acknowledgements
The authors have no conflicts of interest that are directly relevant to the content of this article. No funding was received for the preparation of this review.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Fava, G.A., Tomba, E. New modalities of assessment and treatment planning in depression. CNS Drugs 24, 453–465 (2010). https://doi.org/10.2165/11531580-000000000-00000
Published:
Issue Date:
DOI: https://doi.org/10.2165/11531580-000000000-00000