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The Role of the Alliance in the Pharmacologic Treatment of Depression

J Clin Psychiatry 1997;58(5):196-204

Background: The purpose of this study was to determine the influence of the therapeutic alliance on the efficacy of pharmacotherapy for depression.

Method: The sample consisted of 31 depressed outpatients treated with antidepressants. The alliance was measured by the patient and therapist versions of the California Pharmacotherapy Alliance Scale. Treatment outcome was measured by the Hamilton Rating Scale for Depression and the Beck Depression Inventory, and the Symptom, Sign, Side-Effect Checklist was also completed.

Results: The alliance measures accounted for between 21% and 56% of the variance in the three outcome measures. By averaging across outcome measures, therapist perceptions of the alliance predicted 41% of the variance in improvement in depressive symptoms, where patient perceptions predicted 25%. Scores on both alliance measures were lower than those reported in studies of psychotherapy. Patient attitude toward medication was correlated with somatic complaints, but not with depression scores. Therapist perception of patient hostility correlated with patient depression. Patients differed in the way their alliance and outcome interacted, so that the association might be positive or negative.

Conclusion: Alliance is correlated with outcome in pharmacotherapy management of depression, although there may be interindividual variability across patients. In the pharmacotherapy of depression, therapist perception of alliance is a better predictor of symptom outcome than patient perception, while the reverse is usually found in psychotherapy.