Cognitive-Behavioral Therapy Added to Fluoxetine in Major Depressive Disorder after 4 Weeks of Fluoxetine-Treatment: 16-Week Open Label Study
Narong Maneeton MD*, Annop Thongkam MNS**, Benchalak Maneeton MD*
Affiliation : * Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand ** Suanprung Psychiatric Hospital, Chiang Mai, Thailand
Background : Major depressive disorder (MDD) not responding to antidepressant treatment poses challenges
in planning therapy and prognostic uncertainties. Adjunctive treatment to antidepressants with cognitive-
behavioral therapy (CBT) may be useful for these patients.
Objective : Determine the efficacy of CBT augmentation in patients with MDD not responding to fluoxetine.
Material and Method: Ten patients diagnosed with MDD, by Diagnostic and Statistical Manual of Mental
Disorders Fourth edition (DSM-IV) criteria between December 2007 and July 2008 were enrolled to the
present study. All patients had taken fluoxetine at least 20 mg a day and for at least 4 weeks prior to consent.
Baseline Montgomery Asberg Depression Rating Scale (MADRS) ratings were all moderate to severe (22-44
point). The maximum number of sessions of CBT was 16. Patients treated with CBT for at least 8 weeks were
defined as the completed treatment group. Response was defined as a reduction in MADRS score by at least 50
percent from baseline and remission was defined as a reduction in score of 10 or less.
Results : Fluoxetine augmentation with CBT was a significantly effective treatment in patients with MDD not
responding to 4 week-fluoxetine treatment alone according to MADRS, Clinical Global Impression-Severity
of illness and the 9-item Patient Health Questionnaire, Thai Version (p < 0.001, p = 0.002 and 0.004
respectively). The overall response and remission rates were 100% and 70% respectively. The VAS satisfaction
scores increased from baseline significantly (p < 0.001). Overall quality of life of all patients by WHOQOL-
BREF was improved significantly (p < 0.001).
Conclusion : Adding CBT to fluoxetine in patients with MDD who did not respond to 4 weeks treatment of
fluoxetine had significantly more efficacy than previous fluoxetine treatment alone. With no control group, a
randomized and controlled method might substantiate these promising preliminary findings.
Keywords : Cognitive-behavioral therapy, Major depressive disorder, Fluoxetine
