The therapeutic alliance - its impact on antidepressant therapies in major depressive conditions and on the overall health.

BACKGROUND: Based on our 2012 study and a review of the literature on the therapeutic alliance we asked ourselves different questions: does the alliance exert a real influence on the evolution of depressive affects, the rate of remission and the physical and global health? SUBJECTS AND METHODS: In a two-year study, forty people with major depressive disorder are randomly assigned to groups that receive a SSRI (escitalopram) or a SNRI (duloxetine), each group receive concomitant ASA (100 mg) or a placebo. Sociodemographic data are recorded and patients under went regular assessments with the Hamilton depression scale (HDS) and Clinical Global Impression (CGI) scale, the Helping Alliance Questionnaire (HAQ) and the Short Form Health Survey (SF-12). RESULTS: There is no significant difference in efficacy between the two antidepressants or between antidepressant treatment with and without ASA. However, subgroup comparisons reveal that the duloxetine + ASA (DASA) subgroup showed a more rapid improvement in HDS score as early as 2 months (t=-3.114, p=0.01), in CGI score at 5 months (t=-2.119, p 0.05) than the escitalopram + placebo (EP) subgroup. Regardless of the treatment arm, the remission rate at 2 years is 50%. Among patients in remission a majority, 65%, have a high level of alliance in opposition to nonresponders who have found mostly a low level of alliance (χ2=6.296, p 0.012). HAQ scores are not correlated with HAD scores, but a correlation is found with remission rates (r=0.316*). At all times, HAQ scores are correlated with physical health. CONCLUSION: Our findings suggest that a noradrenergic agent combined with ASA is more effective in treating depression than a serotonergic agent alone. A good alliance improves effectiveness of anti-depressant treatment of 1.85 and leads to an improvement of the physical health rather than directly on the depressive feelings.