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Vittengl JR, Jarrett RB, Weitz E, Hollon SD, Twisk J, Cristea I, David D, DeRubeis RJ, Dimidjian S, Dunlop BW, Faramarzi M, Hegerl U, Kennedy SH, Kheirkhah F, Mergl R, Miranda J, Mohr DC, Rush AJ, Segal ZV, Siddique J, Simons AD, Cuijpers P. Divergent Outcomes in Cognitive-Behavioral Therapy and Pharmacotherapy for Adult Depression. Am J Psychiatry 2016; 173:481-90. [PMID: 26869246 PMCID: PMC4934129 DOI: 10.1176/appi.ajp.2015.15040492] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Although the average depressed patient benefits moderately from cognitive-behavioral therapy (CBT) or pharmacotherapy, some experience divergent outcomes. The authors tested frequencies, predictors, and moderators of negative and unusually positive outcomes. METHOD Sixteen randomized clinical trials comparing CBT and pharmacotherapy for unipolar depression in 1,700 patients provided individual pre- and posttreatment scores on the Hamilton Depression Rating Scale (HAM-D) and/or Beck Depression Inventory (BDI). The authors examined demographic and clinical predictors and treatment moderators of any deterioration (increase ≥1 HAM-D or BDI point), reliable deterioration (increase ≥8 HAM-D or ≥9 BDI points), extreme nonresponse (posttreatment HAM-D score ≥21 or BDI score ≥31), superior improvement (HAM-D or BDI decrease ≥95%), and superior response (posttreatment HAM-D or BDI score of 0) using multilevel models. RESULTS About 5%-7% of patients showed any deterioration, 1% reliable deterioration, 4%-5% extreme nonresponse, 6%-10% superior improvement, and 4%-5% superior response. Superior improvement on the HAM-D only (odds ratio=1.67) and attrition (odds ratio=1.67) were more frequent in pharmacotherapy than in CBT. Patients with deterioration or superior response had lower pretreatment symptom levels, whereas patients with extreme nonresponse or superior improvement had higher levels. CONCLUSIONS Deterioration and extreme nonresponse and, similarly, superior improvement and superior response, both occur infrequently in randomized clinical trials comparing CBT and pharmacotherapy for depression. Pretreatment symptom levels help forecast negative and unusually positive outcomes but do not guide selection of CBT versus pharmacotherapy. Pharmacotherapy may produce clinician-rated superior improvement and attrition more frequently than does CBT.
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Affiliation(s)
- Jeffrey R. Vittengl
- Address correspondence to: Jeffrey R. Vittengl, Department of Psychology, Truman State University, 100 East Normal Street, Kirksville, MO 63501-4221, USA.
| | - Robin B. Jarrett
- Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, USA
| | - Erica Weitz
- Department of Clinical Psychology and EMGO Institute for Health and Care Research, Amsterdam, VU University Amsterdam, The Netherlands
| | | | - Jos Twisk
- EMGO Institute for Health and Care Research, Amsterdam, VU University Amsterdam, The Netherlands
| | - Ioana Cristea
- Department of Clinical Psychology and Psychotherapy, Babes-Bolyai University, Cluj, Romania
| | - Daniel David
- Department of Clinical Psychology and Psychotherapy, Babes-Bolyai University, Cluj, Romania
| | | | - Sona Dimidjian
- Department of Psychology and Neuroscience, University of Colorado, Boulder, USA
| | - Boadie W. Dunlop
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, USA
| | - Mahbobeh Faramarzi
- Fatemeh Zahra Infertility and Reproductive Health Research Center, Babol University of Medical Sciences, Babol, Iran
| | - Ulrich Hegerl
- Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany
| | | | - Farzan Kheirkhah
- Department of Psychiatry, Faculty of Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Roland Mergl
- Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany
| | - Jeanne Miranda
- Health Services Research Center, Neuropsychiatric Institute, University of California, Los Angeles, USA
| | - David C. Mohr
- Center for Behavioral Intervention Technologies, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - A. John Rush
- Duke–National University of Singapore Graduate Medical School, Singapore
| | - Zindel V. Segal
- Department of Psychology, University of Toronto – Scarborough, Toronto, Canada
| | - Juned Siddique
- Department of Preventative Medicine, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Anne D. Simons
- Department of Psychology, University of Notre Dame, Notre Dame, USA
| | - Pim Cuijpers
- Department of Clinical Psychology and EMGO Institute for Health and Care Research, Amsterdam, VU University Amsterdam, The Netherlands
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Kamenov K, Cabello M, Caballero FF, Cieza A, Sabariego C, Raggi A, Anczewska M, Pitkänen T, Ayuso-Mateos JL. Factors Related to Social Support in Neurological and Mental Disorders. PLoS One 2016; 11:e0149356. [PMID: 26900847 PMCID: PMC4764676 DOI: 10.1371/journal.pone.0149356] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 01/29/2016] [Indexed: 02/08/2023] Open
Abstract
Despite the huge body of research on social support, literature has been primarily focused on its beneficial role for both physical and mental health. It is still unclear why people with mental and neurological disorders experience low levels of social support. The main objective of this study was to explore what are the strongest factors related to social support and how do they interact with each other in neuropsychiatric disorders. The study used cross-sectional data from 722 persons suffering from dementia, depression, epilepsy, migraine, multiple sclerosis, Parkinson's disease, schizophrenia, stroke, and substance use disorders. Multiple linear regressions showed that disability was the strongest factor for social support. Extraversion and agreeableness were significant personality variables, but when the interaction terms between personality traits and disability were included, disability remained the only significant variable. Moreover, level of disability mediated the relationship between personality (extraversion and agreeableness) and level of social support. Moderation analysis revealed that people that had mental disorders experienced lower levels of support when being highly disabled compared to people with neurological disorders. Unlike previous literature, focused on increasing social support as the origin of improving disability, this study suggested that interventions improving day-to-day functioning or maladaptive personality styles might also have an effect on the way people perceive social support. Future longitudinal research, however, is warranted to explore causality.
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Affiliation(s)
- Kaloyan Kamenov
- Instituto de Salud Carlos III, Centro Investigación Biomédica en Red, CIBER, Madrid, Spain
| | - Maria Cabello
- Instituto de Salud Carlos III, Centro Investigación Biomédica en Red, CIBER, Madrid, Spain
| | | | - Alarcos Cieza
- Faculty of Social and Human Sciences, School of Psychology, University of Southampton, Southampton, United Kingdom
- Department of Medical Informatics, Biometry and Epidemiology-IBE, Chair for Public Health and Health Services, Research, Research Unit for Biopsychosocial Health, Ludwig-Maximilians-University (LMU), Munich, Germany
- Swiss Paraplegic Research, Nottwil, Switzerland
| | - Carla Sabariego
- Department of Medical Informatics, Biometry and Epidemiology-IBE, Chair for Public Health and Health Services, Research, Research Unit for Biopsychosocial Health, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Alberto Raggi
- Neurological Institute "C. Besta" IRCCS Foundation, Neurology, Public Health and Disability Unit, Milan, Italy
| | - Marta Anczewska
- Department of Psychiatry, Institute of Psychiatry and Neurology, Warsaw, Poland
| | | | - Jose Luis Ayuso-Mateos
- Instituto de Salud Carlos III, Centro Investigación Biomédica en Red, CIBER, Madrid, Spain
- Department of Psychiatry, Universidad Autónoma de Madrid, Madrid, Spain
- Instituto de investigación de la Princesa, (IIS-IP), Hospital Universitario de la Princesa, Madrid, Spain
- * E-mail:
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Hudson JL, Bower P, Archer J, Coventry PA. Does collaborative care improve social functioning in adults with depression? The application of the WHO ICF framework and meta-analysis of outcomes. J Affect Disord 2016; 189:379-91. [PMID: 26476422 DOI: 10.1016/j.jad.2015.09.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 09/04/2015] [Accepted: 09/18/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND Collaborative care has proven efficacy in improving symptoms of depression, yet patients value improvements in their social function also. We used the World Health Organisation's International classification of functioning, disability, and health (WHO ICF) to robustly identify measures of social function and explored whether collaborative care interventions improve social functioning using meta-analysis. METHODS We performed a secondary data analysis on studies identified from our previous Cochrane review of collaborative care interventions for depression and search update (December 2013). The WHO ICF framework was applied to identify studies that included self-report measures of social functioning. Outcomes were extracted at short-term (6 months) and medium-term (≥7 months) and analysed using random-effects meta-analysis. The relationship between improvements in depression outcomes and improvements in social functioning was also explored using bivarable meta-regression. RESULTS Eighteen trials were identified that measured social functioning and met our remaining inclusion criteria. Collaborative care was associated with small improvements in social functioning in the short (Standardised Mean Difference, SMD=0.23, 95% confidence interval 0.12 to 0.34) and medium term (SMD=0.19, 95% confidence interval 0.09 to 0.29). Improvements in depressive symptoms were associated with moderate improvements in social function (ß=-0.55, 95% confidence interval -0.82 to -0.28) but cross-sectionally only. LIMITATIONS The small number of studies (N=18) prevented more complex analyses to explore moderators of social functioning outcomes. CONCLUSIONS Collaborative care improves social functioning but the mechanisms through which this occurs are unknown. Future depression interventions need to consider a person's degree of social function equally alongside their depressive symptoms.
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Affiliation(s)
- Joanna L Hudson
- Health Psychology Section, Psychology Department, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, UK; NIHR School for Primary Care Research and Manchester Academic Health Science Centre University of Manchester, UK
| | - Peter Bower
- NIHR School for Primary Care Research and Manchester Academic Health Science Centre University of Manchester, UK
| | - Janine Archer
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester M13 9PL, UK
| | - Peter A Coventry
- NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) - Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, UK.
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Schramm E, Zobel I, Schoepf D, Fangmeier T, Schnell K, Walter H, Drost S, Schmidt P, Brakemeier EL, Berger M, Normann C. Cognitive Behavioral Analysis System of Psychotherapy versus Escitalopram in Chronic Major Depression. PSYCHOTHERAPY AND PSYCHOSOMATICS 2015; 84:227-40. [PMID: 26022410 DOI: 10.1159/000381957] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 03/30/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND A specific psychotherapy for chronic depression, the Cognitive Behavioral Analysis System of Psychotherapy (CBASP), was compared to escitalopram (ESC). METHODS Sixty patients with chronic major depression were randomized to 'CBASP' (22 sessions) or 'ESC plus clinical management' (ESC/CM) at two treatment sites. The primary outcome measure was the score on the Montgomery-Asberg Depression Rating Scale (MADRS) after 8 weeks of acute treatment assessed by blinded raters. In the case of nonimprovement (<20% reduction in the MADRS score), the other condition was augmented for the following 20 weeks of extended treatment. Secondary end points were, among others, depressive symptoms, remission (MADRS score of ≤9) and response rates (reduction of MADRS score of ≥50%) 28 weeks after randomization. RESULTS An intent-to-treat analysis revealed that clinician-rated depression scores decreased significantly after 8 and 28 weeks with no significant differences between the groups. The response rates after 28 weeks of treatment were high (CBASP: 68.4%, ESC/CM: 60.0%), and the remission rates were moderate (CBASP: 36.8%, ESC/CM: 50.0%) with neither group being superior. Nonimprovers to the initial treatment caught up with the initial improvers in terms of depression scores and response and remission rates by the end of the treatment after being augmented with the respective other condition. CONCLUSIONS CBASP and ESC/CM appear to be equally effective treatment options for chronically depressed outpatients. For nonimprovers to the initial treatment, it is efficacious to augment with medication in the case of nonresponse to CBASP and vice versa.
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Affiliation(s)
- Elisabeth Schramm
- Department of Psychiatry and Psychotherapy, University Medical Center Freiburg, Freiburg, Germany
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Knekt P, Heinonen E, Härkäpää K, Järvikoski A, Virtala E, Rissanen J, Lindfors O, Helsinki Psychotherapy Study Group. Randomized trial on the effectiveness of long- and short-term psychotherapy on psychosocial functioning and quality of life during a 5-year follow-up. Psychiatry Res 2015; 229:381-8. [PMID: 26162657 DOI: 10.1016/j.psychres.2015.05.113] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 05/09/2015] [Accepted: 05/25/2015] [Indexed: 10/23/2022]
Abstract
Knowledge is incomplete on whether long-term psychotherapy is more effective than short-term therapy in treating mood and anxiety disorder, when measured by improvements in psychosocial functioning and life quality. In the Helsinki Psychotherapy Study, 326 outpatients with mood or anxiety disorder were randomized to solution-focused therapy (SFT), short-term psychodynamic psychotherapy (SPP), or long-term psychodynamic psychotherapy (LPP), and followed up for 5 years from the start of treatment. The outcome measures comprised 4 questionnaires on psychosocial functioning, assessing global social functioning (Social Adjustment Scale (SAS-SR), sense of coherence (Sense of Coherence Scale (SOC)), perceived competence (Self-Performance Survey), dispositional optimism (Life Orientation Test (LOT)), and 1 questionnaire assessing quality of life (Life Situation Survey (LSS)). Short-term therapies improved psychosocial functioning and quality of life more than LPP during the first year. The only exceptions were LOT and perceived competence, which did not differ between SPP and LPP. Later in the follow-up, SOC and perceived competence showed significantly more improvement in LPP than in the short-term therapy groups. No direct differences between SFT and SPP were noted. Short-term therapy has consistently more short-term effects on psychosocial functioning and quality of life than LPP, whereas LPP has some additional long-term benefits on psychosocial functioning.
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Affiliation(s)
- Paul Knekt
- National Institute for Health and Welfare, Helsinki, Finland; Biomedicum Helsinki, Helsinki, Finland.
| | - Erkki Heinonen
- National Institute for Health and Welfare, Helsinki, Finland
| | | | | | - Esa Virtala
- National Institute for Health and Welfare, Helsinki, Finland
| | - Julius Rissanen
- National Institute for Health and Welfare, Helsinki, Finland
| | - Olavi Lindfors
- National Institute for Health and Welfare, Helsinki, Finland
| | - Helsinki Psychotherapy Study Group
- National Institute for Health and Welfare, Helsinki, Finland; Biomedicum Helsinki, Helsinki, Finland; University of Lapland, Rovaniemi, Finland; Rehabilitation Foundation, Helsinki, Finland; Social Insurance Institution, Finland
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The relationship between symptom relief and functional improvement during acute fluoxetine treatment for patients with major depressive disorder. J Affect Disord 2015; 182:115-20. [PMID: 25985380 DOI: 10.1016/j.jad.2015.04.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 04/12/2015] [Accepted: 04/13/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND The purpose of this study was to compare the rate of symptom relief to functional improvement and examine the relationships between symptom relief and functional improvement during the acute phase of treatment. METHODS A total of 131 acutely ill inpatients with major depressive disorder were enrolled to receive 20mg of fluoxetine daily for 6 weeks. Symptom severity, using the 17-item Hamilton Depression Rating Scale (HAMD-17), and functioning, using the Modified Work and Social Adjustment Scale (MWSAS), were measured regularly. The outcome measures were the HAMD-17 score and MWSAS score at weeks 1, 2, 3, 4, and 6. We compared the effect size and the reduction rate of HAMD-17 to those of MWSAS at week 1, 2, 3, 4, and 6. Structural equation modeling was used to examine relationships among the study variables. RESULTS Of the 131 participants, 126 had at least one post-baseline assessment at week 1 and were included in the analysis. The HAMD-17 had a larger effect size and reduction rate than the MWSAS at weeks 1, 2, 3, 4, and 6. Parsimonious model satisfied all indices of goodness-of-fit (Chi-Square/df=1.479, TLI=0.978, CFI=0.986, RMSEA=0.062) and had all paths with significant path coefficients. MWSAS at week 0 predicted HAMD-17 at week 1. LIMITATION This was an open-labeled study with small sample size. CONCLUSION Depressive symptoms improved more quickly than functioning during the acute phase of treatment. Depressive symptoms and functional impairment are distinct domains, and should be assessed independently.
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Fountoulakis KN, McIntyre RS, Carvalho AF. From Randomized Controlled Trials of Antidepressant Drugs to the Meta-Analytic Synthesis of Evidence: Methodological Aspects Lead to Discrepant Findings. Curr Neuropharmacol 2015; 13:605-15. [PMID: 26467410 PMCID: PMC4761632 DOI: 10.2174/1570159x13666150630174343] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 01/20/2015] [Accepted: 01/20/2015] [Indexed: 01/20/2023] Open
Abstract
During the last decade, several meta-analytic studies employing different methodological approaches have had inconsistent conclusions regarding antidepressant efficacy. Herein, we aim to comment on methodological aspects that may have contributed to disparate findings. We initially discuss methodological inconsistencies and limitations related to the conduct of individual antidepressant randomized controlled trials (RCTs), including differences in allocated samples, limitations of psychometric scales, possible explanations for the heightened placebo response rates in antidepressant RCTs across the past two decades as well as the reporting of conflicts of interest. In the second part of this article, we briefly describe the various meta-analyses techniques (e.g., simple random effects meta-analysis and network meta-analysis) and the application of these methods to synthesize evidence related to antidepressant efficacy. Recently published antidepressant metaanalyses often provide discrepant results and similar results often lead to different interpretations. Finally, we propose strategies to improve methodology considering real-world clinical scenarios.
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Affiliation(s)
| | | | - André F Carvalho
- 6, Odysseos str (1st Parodos Ampelonon str.), 55535 Pylaia Thessaloniki, Greece.
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The effects of psychotherapy for adult depression on social support: A meta-analysis. COGNITIVE THERAPY AND RESEARCH 2014; 38:600-611. [PMID: 26085699 DOI: 10.1007/s10608-014-9630-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Social support is an important extra-therapeutic context of depression treatment, yet no overall estimate is available on how depression treatment affects social support or the size of such an effect. We conducted a meta-analysis of clinical trials of psychotherapy for depression that reported results for social support at post-treatment. A total of 1,579 adults with depression from 11 trials comparing psychotherapy to care-as-usual or waiting list were included. The majority of these studies assessed the participants' perceptions of social support. Specifically, three studies targeted women with postpartum depression, and four studies targeted individuals with chronic disease. In all these studies, psychotherapy had a small to moderate, yet consistent effect on social support compared to care-as-usual or waiting list at post-treatment (g = 0.38; 95% CI: 0.29~0.48) and at 3-6 month follow-up (g= 0.38; 95% CI: 0.14~0.63). Little evidence of heterogeneity was found across studies, and the results were consistent in several sensitivity analyses. No significant publication bias was detected (Egger's test p > 0.1). The result of meta-regression showed that improvement in depression symptoms was associated with improvement in social support, but this was not statistically significant.
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