Reducing relapse and recurrence in unipolar depression: a comparative meta-analysis of cognitive-behavioral therapy's effects

A review of cognitive therapy in acute medical settings. Part I: Therapy model and assessment

Introduction:

Although cognitive therapy (CT) has established outpatient utility, there is no integrative framework for using CT in acute medical settings where most psychosomatic medicine (P-M) clinicians practice. Biopsychosocial complexity challenges P-M clinicians who want to use CT as the a priori psychotherapeutic modality. For example, how should clinicians modify the data gathering and formulation process to support CT in acute settings?

Method:

Narrative review methodology is used to describe the framework for a CT informed interview, formulation, and assessment in acute medical settings. Because this review is aimed largely at P-M trainees and educators, exemplary dialogues model the approach (specific CT strategies for common P-M scenarios appear in the companion article.)

Results:

Structured data gathering needs to be tailored by focusing on cognitive processes informed by the cognitive hypothesis. Agenda setting, Socratic questioning, and adaptations to the mental state examination are necessary. Specific attention is paid to the CT formulation, Folkman's Cognitive Coping Model, self-report measures, data-driven evaluations, and collaboration (e.g., sharing the formulation with the patient.) Integrative CT-psychopharmacological approaches and the importance of empathy are emphasized.

Significance of results:

The value of implementing psychotherapy in parallel with data gathering because of time urgency is advocated, but this is a significant departure from usual outpatient approaches in which psychotherapy follows evaluation. This conceptual approach offers a novel integrative framework for using CT in acute medical settings, but future challenges include demonstrating clinical outcomes and training P-M clinicians so as to demonstrate fidelity.

Interventions for preventing relapse and recurrence of a depressive disorder in children and adolescents

BACKGROUND

Depressive disorders often begin during childhood or adolescence. There is a growing body of evidence supporting effective treatments during the acute phase of a depressive disorder. However, little is known about treatments for preventing relapse or recurrence of depression once an individual has achieved remission or recovery from their symptoms.

OBJECTIVES

To determine the efficacy of early interventions, including psychological and pharmacological interventions, to prevent relapse or recurrence of depressive disorders in children and adolescents.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) (to 1 June 2011). The CCDANCTR contains reports of relevant randomised controlled trials from The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). In addition we handsearched the references of all included studies and review articles.

SELECTION CRITERIA

Randomised controlled trials using a psychological or pharmacological intervention, with the aim of preventing relapse or recurrence from an episode of major depressive disorder (MDD) or dysthymic disorder (DD) in children and adolescents were included. Participants were required to have been diagnosed with MDD or DD according to DSM or ICD criteria, using a standardised and validated assessment tool.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all trials for inclusion in the review, extracted trial and outcome data, and assessed trial quality. Results for dichotomous outcomes are expressed as odds ratio and continuous measures as mean difference or standardised mean difference. We combined results using random-effects meta-analyses, with 95% confidence intervals. We contacted lead authors of included trials and requested additional data where possible.

MAIN RESULTS

Nine trials with 882 participants were included in the review. In five trials the outcome assessors were blind to the participants' intervention condition and in the remainder of trials it was unclear. In the majority of trials, participants were either not blind to their intervention condition, or it was unclear whether they were or not. Allocation concealment was also unclear in the majority of trials. Although all trials treated participants in an outpatient setting, the designs implemented in trials was diverse, which limits the generalisability of the results. Three trials indicated participants treated with antidepressant medication had lower relapse-recurrence rates (40.9%) compared to those treated with placebo (66.6%) during a relapse prevention phase (odds ratio (OR) 0.34; 95% confidence interval (CI) 0.18 to 0.64, P = 0.02). One trial that compared a combination of psychological therapy and medication to medication alone favoured a combination approach over medication alone, however this result did not reach statistical significance (OR 0.26; 95% CI 0.06 to 1.15). The majority of trials that involved antidepressant medication reported adverse events including suicide-related behaviours. However, there were not enough data to show which treatment approach results in the most favourable adverse event profile.

AUTHORS' CONCLUSIONS

Currently, there is little evidence to conclude which type of treatment approach is most effective in preventing relapse or recurrence of depressive episodes in children and adolescents. Limited trials found that antidepressant medication reduces the chance of relapse-recurrence in the future, however, there is considerable diversity in the design of trials, making it difficult to compare outcomes across studies. Some of the research involving psychological therapies is encouraging, however at present more trials with larger sample sizes need to be conducted in order to explore this treatment approach further.

The third wave of cognitive behavioural therapies: what is new and what is effective?

PURPOSE OF REVIEW

The purpose of this study was to shortly characterize the evolving psychotherapeutic methods summarized as 'third wave psychotherapies' and to review recent research on the therapeutic impact of these methods.

RECENT FINDINGS

'Third wave psychotherapies' comprise a heterogeneous group of treatments, including acceptance and commitment treatment, behavioural activation, cognitive behavioural analysis system of psychotherapy, dialectical behavioural therapy, metacognitive therapy, mindfulness-based cognitive therapy and schema therapy. Several randomized controlled trials, longitudinal case series and pilot studies have been performed during the past 3-5 years, showing the efficacy and effectiveness of 'third wave psychotherapies'.

SUMMARY

The third wave of behavioural psychotherapies is an important arena of modern psychotherapy. It has added considerably to the spectrum of empirically supported treatments for mental disorders and influenced research on psychotherapy. The presented methods open up treatment possibilities for patient groups such as borderline personality disorder, chronic depression or generalized anxiety disorder that had received only little specific attention in the past. The available evidence now allows considering all third wave treatments as empirically supported.

Efficacy of an adjunctive brief psychodynamic psychotherapy to usual inpatient treatment of depression: rationale and design of a randomized controlled trial

BACKGROUND

A few recent studies have found indications of the effectiveness of inpatient psychotherapy for depression, usually of an extended duration. However, there is a lack of controlled studies in this area and to date no study of adequate quality on brief psychodynamic psychotherapy for depression during short inpatient stay exists. The present article describes the protocol of a study that will examine the relative efficacy, the cost-effectiveness and the cost-utility of adding an Inpatient Brief Psychodynamic Psychotherapy to pharmacotherapy and treatment-as-usual for inpatients with unipolar depression.

METHODS/DESIGN

The study is a one-month randomized controlled trial with a two parallel group design and a 12-month naturalistic follow-up. A sample of 130 consecutive adult inpatients with unipolar depression and Montgomery-Asberg Depression Rating Scale score over 18 will be recruited. The study is carried out in the university hospital section for mood disorders in Lausanne, Switzerland. Patients are assessed upon admission, and at 1-, 3- and 12- month follow-ups. Inpatient therapy is a manualized brief intervention, combining the virtues of inpatient setting and of time-limited dynamic therapies (focal orientation, fixed duration, resource-oriented interventions). Treatment-as-usual represents the best level of practice for a minimal treatment condition usually proposed to inpatients. Final analyses will follow an intention-to-treat strategy. Depressive symptomatology is the primary outcome and secondary outcome includes measures of psychiatric symptomatology, psychosocial role functioning, and psychodynamic-emotional functioning. The mediating role of the therapeutic alliance is also examined. Allocation to treatment groups uses a stratified block randomization method with permuted block. To guarantee allocation concealment, randomization is done by an independent researcher.

DISCUSSION

Despite the large number of studies on treatment of depression, there is a clear lack of controlled research in inpatient psychotherapy during the acute phase of a major depressive episode. Research on brief therapy is important to take into account current short lengths of stay in psychiatry. The current study has the potential to scientifically inform appropriate inpatient treatment. This study is the first to address the issue of the economic evaluation of inpatient psychotherapy.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry (ACTRN12612000909820).

Cost-effectiveness of nurse-led self-help for recurrent depression in the primary care setting: design of a pragmatic randomised controlled trial

BACKGROUND

Major Depressive Disorder is a leading cause of disability, tends to run a recurrent course and is associated with substantial economic costs due to increased healthcare utilization and productivity losses. Interventions aimed at the prevention of recurrences may reduce patients' suffering and costs. Besides antidepressants, several psychological treatments such as preventive cognitive therapy (PCT) are effective in the prevention of recurrences of depression. Yet, many patients find long-term use of antidepressants unattractive, do not want to engage in therapy sessions and in the primary care setting psychologists are often not available. Therefore, it is important to study whether PCT can be used in a nurse-led self-help format in primary care. This study sets out to test the hypothesis that usual care plus nurse-led self-help for recurrent depression in primary care is feasible, acceptable and cost-effective compared to usual care only.

DESIGN

Patients are randomly assigned to 'nurse-led self-help treatment plus usual care' (134 participants) or 'usual care' (134 participants). Randomisation is stratified according to the number of previous episodes (2 or 3 previous episodes versus 4 or more). The primary clinical outcome is the cumulative recurrence rate of depression meeting DSM-IV criteria as assessed by the Structured-Clinical-Interview-for-DSM-IV- disorders at one year after completion of the intervention. Secondary clinical outcomes are quality of life, severity of depressive symptoms, co-morbid psychopathology and self-efficacy. As putative effect-moderators, demographic characteristics, number of previous episodes, type of treatment during previous episodes, age of onset, self-efficacy and symptoms of pain and fatigue are assessed. Cumulative recurrence rate ratios are obtained under a Poisson regression model. Number-needed-to-be-treated is calculated as the inverse of the risk-difference. The economic evaluation is conducted from a societal perspective, both as a cost-effectiveness analysis (costs per depression free survival year) and as a cost-utility analysis (costs per quality adjusted life-year).

DISCUSSION

The purpose of this paper is to outline the rationale and design of a nurse-led, cognitive therapy based self-help aimed at preventing recurrence of depression in a primary care setting. Only few studies have focused on psychological self-help interventions aimed at the prevention of recurrences in primary care patients.

TRIAL REGISTRATION

NTR3001 (http://www.trialregister.nl).

Cognitive behavioral therapy for depression

CBT is a valuable treatment for mild, moderate, and severe forms of major depression. It is equally effective and more durable than medication alone, and the combination of medication and CBT may increase the response rate and extend durability when CBT is employed after pharmacotherapy is successful. Therapist competence has been shown to influence outcomes in CBT for depression. Practitioners who wish to learn more about CBT may access a wide variety of educational materials: basic texts, course offerings at major scientific meetings, and local and national training centers are available. The Academy of Cognitive Therapy website (www.academyofct.org) provides detailed information about obtaining training and certification in CBT.

Cognitive reactivity, dysfunctional attitudes, and depressive relapse and recurrence in cognitive therapy responders

Dysfunctional attitudes can foreshadow depressive relapse/recurrence. Priming mood, through induction paradigms, is hypothesized to activate dysfunctional attitudes. Cognitive reactivity (CR) refers to mood-linked increases in dysfunctional attitudes after priming. Here we explored the extent to which CR as well as residual, unprimed, dysfunctional attitudes predicted depressive relapse/recurrence among depressed patients who responded to acute phase cognitive therapy (CT). Consenting adults, aged 18-70, with recurrent major depressive disorder (n = 523) participated in a two-site randomized controlled trial examining the durability of continuation phase treatments. Patients received 16-20 sessions of CT. Among the 245 incompletely remitted responders, 213 agreed to undergo a mood induction paradigm. After 8 months of continuation phase treatments, participants were followed an additional 24 months. Although the mood induction significantly lowered mood in 80% of responders, the expected CR was not evident. By contrast, higher unprimed dysfunctional attitudes following CT did predict relapse/recurrence over 20 and 32 months post-randomization. The findings of this large longitudinal study of incompletely remitted CT responders challenge the notion that it is necessary to prime mood in order to maximize dysfunctional attitudes' prediction of relapse and/or recurrence. While findings cannot be generalized beyond CT responders, they emphasize the clinical importance of reducing dysfunctional attitudes in preventing depression.

"Barriers to Cognitive Behavioral Therapy Homework Completion Scale- Depression Version": Development and Psychometric Evaluation

We conducted a two-phase study to develop and evaluate the psychometric properties of an instrument to identify barriers to Cognitive Behavioral Therapy (CBT) homework completion in a depressed sample. In Phase I, we developed an item pool by interviewing 20 depressed patients and 20 CBT therapists. In Phase II, we created and administered a draft instrument to 56 people with depression. Exploratory Factor Analysis revealed a 2-factor oblique solution of "Patient Factors" and "Therapy/Task Factors." Internal consistency coefficients ranged from .80 to .95. Temporal stability was demonstrated through Pearson correlations of .72 (for the therapist/task subscale) to .95 (for the patient subscale) over periods of time that ranged from 2 days to 3 weeks. The patient subscale was able to satisfactorily classify patients (75 to 79 %) with low and high adherence at both sessions. Specificity was .66 at both time points. Sensitivity was .80 at sessions B and .77 at session C. There were no consistent predictors of assignment compliance when measured by the Assignment Compliance Rating Scale (Primakoff, Epstein, & Covi, 1986). The Rating Scale and subscale scores did, however, correlate significantly with assignment non-compliance (.32 to .46).

The effect of cognitive behavioral group therapy for depression: a meta-analysis 2000-2010

OBJECTIVE

The goals of the meta-analysis were to investigate the overall effectiveness of cognitive behavioral group therapy (CBGT) for depression and relapse prevention in depression from 2000 to 2010, and to investigate how the variables (episode, residual symptoms, group size, control group, group manual, therapist experience, therapy frequency, session length, and take-home assignment) of a CBGT study could affect the effect size.

METHOD

This study collected actual study designs sought of CBGT for depression published from 2000 to 2010. These studies were then cross-referenced using Medical Subject Headings (MeSH) with the following keywords: group therapy, cognitive therapy, cognitive behavioral therapy, cognitive behavioral group therapy, psychotherapy, depression, relapse, and recurrence. The quality of the studies was evaluated using Cochrane Collaboration Guidelines. The effect size of CBGT on depression and relapse prevention in depression used the formula devised by Hedges and Olkin (1985).

RESULTS

The study investigated the results of 32 studies on the effect of CBGT for depression. The CBGT had an immediate (g=-0.40) and continuous effect over 6 months (g=-0.38), but no continuous effect after 6 months (g=-0.06). The CBGT lowered the relapse rate of depression (RD = 0.16). Variables significantly different from each other in terms of immediate effect were: CBGT versus usual care, therapy sessions lasting longer than 1 hour, and take-home assignments. Preintervention severity of depression and patient turnover rate were found to be significantly related to the size of the immediate effect. The relapse rate after 6 months was significantly related only to "participants have no residual symptoms/participants did not mention residual symptoms."

CONCLUSIONS

Researchers and clinicians should take note that CBGT had a moderate effect on the level of depression and a small effect on the relapse rate of depression. The results of this study suggest that the patient should receive a course of therapy at least every 6 months.

The effects of cognitive therapy versus 'no intervention' for major depressive disorder

BACKGROUND

Major depressive disorder afflicts an estimated 17% of individuals during their lifetimes at tremendous suffering and costs. Cognitive therapy may be an effective treatment option for major depressive disorder, but the effects have only had limited assessment in systematic reviews.

METHODS/PRINCIPAL FINDINGS

We used The Cochrane systematic review methodology with meta-analyses and trial sequential analyses of randomized trials comparing the effects of cognitive therapy versus 'no intervention' for major depressive disorder. Participants had to be older than 17 years with a primary diagnosis of major depressive disorder to be eligible. Altogether, we included 12 trials randomizing a total of 669 participants. All 12 trials had high risk of bias. Meta-analysis on the Hamilton Rating Scale for Depression showed that cognitive therapy significantly reduced depressive symptoms (four trials; mean difference -3.05 (95% confidence interval (Cl), -5.23 to -0.87; P<0.006)) compared with 'no intervention'. Trial sequential analysis could not confirm this result. Meta-analysis on the Beck Depression Inventory showed that cognitive therapy significantly reduced depressive symptoms (eight trials; mean difference on -4.86 (95% CI -6.44 to -3.28; P = 0.00001)). Trial sequential analysis on these data confirmed the result. Only a few trials reported on 'no remission', suicide inclination, suicide attempts, suicides, and adverse events without significant differences between the compared intervention groups.

DISCUSSION

Cognitive therapy might be an effective treatment for depression measured on Hamilton Rating Scale for Depression and Beck Depression Inventory, but these outcomes may be overestimated due to risks of systematic errors (bias) and random errors (play of chance). Furthermore, the effects of cognitive therapy on no remission, suicidality, adverse events, and quality of life are unclear. There is a need for randomized trials with low risk of bias, low risk of random errors, and longer follow-up assessing both benefits and harms with clinically relevant outcome measures.

Psychological treatment of depression: results of a series of meta-analyses

BACKGROUND

In the past few decades, a considerable number of studies have examined the effects of psychotherapies for adult depression.

AIM

We described the results of a series of meta-analyses examining what this large body of research has contributed to our knowledge of these treatments of depression.

RESULTS

We found that different types of psychotherapy are efficacious in the treatment of adult depression, including cognitive behavior therapy, interpersonal psychotherapy, problem-solving therapy, non-directive supportive therapy and behavioral activation therapy. Differences between types of psychotherapy are small. The efficacy of psychotherapy for mild to moderate depression is about the same as the efficacy of pharmacotherapy, and that combined treatment is more effective than psychotherapy alone and pharmacotherapy alone. Psychotherapy is not only effective in depressed adults in general, but also in older adults, women with postpartum depression, patients with general medical disorders, in inpatients, in primary care patients, patients with chronic depression and in subthreshold depression.

CONCLUSIONS

We found no evidence showing that psychotherapy is less efficacious in severe depression (with mean baseline Hamilton Depression Rating Scale scores up to 31, mean Beck Depression Inventory scores up to 35.85 and mean Beck Depression Inventory-II scores up to 36.50), but effects are smaller in chronic depression. We also found that the effects of psychotherapy are probably overestimated because of publication bias and the relatively low quality of many studies in the field.

Use of auxiliary psychiatric treatment during a 5-year follow-up among patients receiving short- or long-term psychotherapy

BACKGROUND

The need for treatment is, despite of its obvious usefulness, a scarcely used measure of effectiveness in psychotherapy trials. This study considers changes in the need for auxiliary psychiatric treatment after starting short- and long-term psychotherapy and psychoanalysis.

METHODS

Altogether 326 psychiatric outpatients with mood or anxiety disorder were randomly assigned to solution-focused therapy (SFT), short-term psychodynamic psychotherapy (SPP), or long-term psychodynamic psychotherapy (LPP) while 41 self-selected patients were allocated to psychoanalysis (PA). The patients were followed for 5 years from start of treatment. Outcome measures were use of auxiliary psychotherapy, psychotropic medication, and hospitalization for mental reasons.

RESULTS

About 60% of the patients used auxiliary treatment during the follow-up. It was most common in the short-term therapy groups and its incidence was highest during the first year after the start of therapy. The average numbers of all therapy sessions among patients starting the therapy were 60, 70, 240, and 670 in SFT, SPP, LPP, and PA, respectively, whereas the corresponding average numbers of study therapy sessions alone were 10, 19, 232, and 646. Over 50% of the patients receiving short-term therapy received on average 4-6 times more therapy sessions than initially assigned.

LIMITATIONS

Post-randomization withdrawal was uneven.

CONCLUSIONS

Auxiliary treatment is usual among patients receiving short- and long-term therapies, and apparently becomes common shortly after the start of treatment. Auxiliary treatment can be used as an outcome measure indicating the need for treatment, should be monitored clinically and considered when interpreting the results of effectiveness studies.

Incidence and predictors of relapse during continuation treatment of major depression with SSRI, interpersonal psychotherapy, or their combination

BACKGROUND

Despite the availability of many effective treatments, patients with major depression remain at risk for relapse following remission of a depressive episode. The aims of this report are to estimate the relapse rates associated with the acute treatment strategies employed in this study and to investigate demographic and clinical predictors of relapse.

METHODS

The study sample includes 225 patients who entered the 6-month continuation treatment phase after remitting from an acute depressive episode. Treatment during the acute phase was interpersonal psychotherapy, SSRI (escitalopram), or the combination of the two when monotherapy did not lead to response. Relapse was defined by a Hamilton Depression Rating Scale score ≥15, confirmed by the diagnosis of major depression. The probability of relapsing was modeled using logistic regression. Three separate models were fit with subgroups of covariates.

RESULTS

Of the 225 patients, 29 (12.9%) relapsed and 28 (12.4%) discontinued the protocol prematurely. The proportion of patients who relapsed among the group requiring combination treatment to achieve remission was three times as high as among patients who had remitted with monotherapy. In the final logistic regression model, older age, higher baseline HDRS scores, last month (residual) depressive mood spectrum factor score, and requiring combination treatment to achieve remission were each associated with an increased likelihood of relapse.

CONCLUSIONS

Our results suggest that greater initial depression severity, greater difficulty in stabilizing symptoms, and presence of residual mood spectrum symptoms once remission is achieved are predictive of relapse. Risk of relapse is more likely as age increases, partly because aging confers lower resilience.

Randomized trial of Internet-based relapse prevention for partially remitted depression

OBJECTIVE

To investigate whether Internet-based cognitive behaviour therapy (CBT) can prevent relapse in persons with partially remitted major depression after previous treatment.

METHOD

Seventy-one women and 13 men (N = 84) with partially remitted major depression after treatment were randomly assigned to either 10 weeks of Internet-based CBT or to a control group. Self-help material was used in combination with e-mail contact with a personal therapist. Monthly self-ratings of depressive symptoms were made, and diagnostic interviews were conducted before and after the treatment period, as well as 6 months later.

RESULTS

Significantly fewer participants in the CBT group experienced relapse (4/38 or 10.5%) compared with those in the control group (14/37 or 37.8%). The difference in relapse rates between groups occurred early in the study period and was still apparent after 6 months. A trend towards a larger reduction in depressive symptoms was observed at post-treatment in the participants who received CBT compared with controls. Reduction in depressive symptoms reduced the risk of relapse. A trend towards a higher remission rate was found in the CBT group at the 6 month follow-up.

CONCLUSION

Internet-based CBT seems promising in preventing relapse in persons with partially remitted major depression after previous treatment.

A 3.5-year follow-up of Internet-delivered cognitive behavior therapy for major depression

BACKGROUND

Internet-delivered cognitive behavior therapy (ICBT) for major depression has been tested in several trials, but only with follow-ups up to 1.5 years.

AIM

The aim of this study was to evaluate the outcome of ICBT 3.5 years after treatment completion.

METHODS

A total of 88 people with major depression were randomized to either guided self-help or e-mail therapy in the original trial. One-third was initially on a waiting-list. Treatment was provided for eight weeks and in this report long-term follow-up data were collected. Also included were data from post-treatment and six-month follow-up. A total of 58% (51/88) completed the 3.5-year follow-up. Analyses were performed using a random effects repeated measures piecewise growth model to estimate trajectory shape over time and account for missing data. Results Results showed continued lowered scores on the Beck Depression Inventory (BDI). No differences were found between the treatment conditions. A large proportion of participants (55%) had sought and received additional treatments in the follow-up period. A majority (56.9%) of participants had a BDI score lower than 10 at the 3.5-year follow-up.

CONCLUSIONS

People with mild to moderate major depression may benefit from ICBT 3.5-years after treatment completion.

Relapse and recurrence prevention in depression: current research and future prospects

There is a growing body of literature which indicates that acute phases of psychotherapy are often ineffective in preventing relapse and recurrence in major depression. As a result, there is a need to develop and evaluate therapeutic approaches which aim to reduce the risk of relapse. This article provides a review of the empirical studies which have tested the prophylactic effects of therapy (cognitive-behavioral, mindfulness-based, and interpersonal psychotherapy) targeting relapse and recurrence in major depression. For definitional clarity, relapse is defined here as a return to full depressive symptomatology before an individual has reached a full recovery, whereas recurrence in defined as the onset of a new depressive episode after a full recovery has been achieved. Psychotherapeutic efforts to prevent relapse and recurrence in depression have been effective to varying degrees, and a number of variables appear to moderate the success of these approaches. A consistent finding has been that preventive cognitive-behavioral and mindfulness-based therapies are most effective for patients with three or more previous depressive episodes, and alternative explanations for this finding are discussed. It is noted, however, that a number of methodological limitations exist within this field of research, and so a set of hypotheses that may guide future studies in this area is provided.

A systematic review of the combined use of electroconvulsive therapy and psychotherapy for depression

OBJECTIVE

Electroconvulsive therapy (ECT) is one of the most effective treatments for severe major depressive disorder. However, after acute-phase treatment and initial remission, relapse rates are significant. Strategies to prolong remission include continuation phase ECT, pharmacotherapy, psychotherapy, or their combinations. This systematic review synthesizes extant data regarding the combined use of psychotherapy with ECT for the treatment of patients with severe major depressive disorder and offers the hypothesis that augmenting ECT with depression-specific psychotherapy represents a promising strategy for future investigation.

METHODS

The authors performed 2 independent searches in PsychInfo (1806-2009) and MEDLINE (1948-2009) using combinations of the following search terms: Electroconvulsive Therapy (including ECT, ECT therapy, electroshock therapy, EST, and shock therapy) and Psychotherapy (including cognitive behavioral, interpersonal, group, psychodynamic, psychoanalytic, individual, eclectic, and supportive). We included in this review a total of 6 articles (English language) that mentioned ECT and psychotherapy in the abstract and provided a case report, series, or clinical trial. We examined the articles for data related to ECT and psychotherapy treatment characteristics, cohort characteristics, and therapeutic outcome.

RESULTS

Although research over the past 7 decades documenting the combined use of ECT and psychotherapy is limited, the available evidence suggests that testing this combination has promise and may confer additional, positive functional outcomes.

CONCLUSIONS

Significant methodological variability in ECT and psychotherapy procedures, heterogeneous patient cohorts, and inconsistent outcome measures prevent strong conclusions; however, existing research supports the need for future investigations of combined ECT and psychotherapy in well-designed, controlled clinical studies. Depression-specific psychotherapy approaches may need special adaptations in view of the cognitive effects of ECT.

How to obtain NNT from Cohen's d: comparison of two methods

BACKGROUND

In the literature we find many indices of size of treatment effect (effect size: ES). The preferred index of treatment effect in evidence-based medicine is the number needed to treat (NNT), while the most common one in the medical literature is Cohen's d when the outcome is continuous. There is confusion about how to convert Cohen's d into NNT.

METHODS

We conducted meta-analyses of individual patient data from 10 randomized controlled trials of second generation antipsychotics for schizophrenia (n = 4278) to produce Cohen's d and NNTs for various definitions of response, using cutoffs of 10% through 90% reduction on the symptom severity scale. These actual NNTs were compared with NNTs calculated from Cohen's d according to two proposed methods in the literature (Kraemer, et al., Biological Psychiatry, 2006; Furukawa, Lancet, 1999).

RESULTS

NNTs from Kraemer's method overlapped with the actual NNTs in 56%, while those based on Furukawa's method fell within the observed ranges of NNTs in 97% of the examined instances. For various definitions of response corresponding with 10% through 70% symptom reduction where we observed a non-small number of responders, the degree of agreement for the former method was at a chance level (ANOVA ICC of 0.12, p = 0.22) but that for the latter method was ANOVA ICC of 0.86 (95%CI: 0.55 to 0.95, p<0.01).

CONCLUSIONS

Furukawa's method allows more accurate prediction of NNTs from Cohen's d. Kraemer's method gives a wrong impression that NNT is constant for a given d even when the event rate differs.

Long-term effect of combined interpersonal psychotherapy and pharmacotherapy in a randomized trial of depressed patients

OBJECTIVE

Evaluation of the long-term benefits of combined pharmacological and psychotherapeutic depression treatment and the differential impact of early childhood trauma.

METHOD

A randomized trial was conducted in 124 in-patients with a diagnosis of major depressive disorder comparing 5 weeks of interpersonal psychotherapy plus pharmacotherapy (IPT) with medication plus clinical management (CM). The study included a prospective, naturalistic follow-up 3, 12 and 75 months after in-patient treatment. The Hamilton Rating Scale for Depression (HRSD) served as the primary outcome measure.

RESULTS

Patients in both treatments reduced their depressive symptoms between baseline and 5-year follow-up significantly with a faster decrease early in the follow-up phase. The time rate of change and acceleration on the HRSD was higher for patients in the combination therapy group. The contrast between the conditions at year 5 was non-significant. However, 28% of the IPT patients showed a sustained remission compared with 11% of the CM patients (P = 0.032). Early adversity was found to be a moderator of the relationship between treatment and outcome.

CONCLUSION

In the long-term, a combination of psycho- and pharmacotherapy was superior in terms of sustained remission rates to standard psychiatric treatment. Early trauma should be assessed routinely in depressed patients.

Feasibility of dissemination of cognitive behavioral therapy to Texas community mental health centers

State mental health systems are actively seeking to disseminate empirically supported treatment approaches to improve the outcomes of adults with serious mental illnesses. However, many of these interventions have not been studied within public mental health settings. Cognitive behavioral therapy (CBT) has been shown to be effective for major depression in well-controlled trials, but its effectiveness in public mental health settings is less known. The present study examines the feasibility of dissemination of CBT in the Texas public mental health system. Seven clinicians were trained by a CBT expert and supervised for 5 months, during which time their skills approached competency levels of therapists in randomized controlled trials. Forty clients were treated during the therapists' training phase, attending an average of ten sessions and experiencing a significant reduction in depressive symptoms. Study results are compared with previously published studies of CBT.

[Evidence-based treatment of depression: what does the new S3- and national healthcare guideline Unipolar Depression really recommend?]

The paper reflects central recommendations and methodological issues of the new German guidelines for the treatment of depression, as discussed in the article New German Guidelines for the Treatment of Depression - The Central Role of Psychotherapy (Schauenburg et al. 2009). Members of the steering group for these guidelines disagree with the authors' description in several points, especially with reference to the efficacy of pharmacotherapy with antidepressants and psychotherapy, as well as the relationship between both strategies of therapy and their combination in diverse phases of treatment (acute/maintenance). Furthermore, we try to clarify some misunderstandings in matters of the guideline's methodology which arose in the paper cited.

One-year follow-up results of unsupported online computerized cognitive behavioural therapy for depression in primary care: A randomized trial

OBJECTIVE

To report the one-year follow-up results of computerized cognitive behavioural therapy (CCBT), offered online without professional support, for depression compared with usual GP care and a combination of both treatments. To explore potential relapse prevention effects of CCBT.

METHODS

303 depressed patients were randomly allocated to (a) unsupported online CCBT (b) treatment as usual (TAU), or (c) CCBT and TAU combined. We had a 12-month follow-up period. Primary outcome measure was the Beck Depression Inventory II. Self-reported health care use was also measured.

KEY FINDINGS

At 12 months, no statistically significant differences between the three interventions are found in the intention-to-treat population for depressive severity, reliable improvement, remission, and relapse. In the first quarter, differences in health care consumption between the three interventions are significant (i.e. less GP contacts, less antidepressant medication, and less specialist mental health care in the CCBT group), but these differences disappear over time.

CONCLUSIONS

Unsupported online CCBT is not superior to TAU by a GP for depression. With equal effects, CCBT alone leads to less health care consumption than TAU and CCBT&TAU. Overall effects are modest in all interventions, which can be explained by the finding that the use of health care services decreases despite the lack of substantial improvements.

Efficacy of the sequential integration of psychotherapy and pharmacotherapy in major depressive disorder: a preliminary meta-analysis

BACKGROUND

Prevention of relapse and recurrence represents an important task in the successful treatment of major depressive disorder (MDD). The aim of this meta-analysis was to examine the efficacy of the sequential integration of psychotherapy and pharmacotherapy in reducing the risk of relapse and recurrence in MDD.

METHOD

Keyword searches were conducted in Medline, EMBASE, PsycINFO and the Cochrane Library from inception of each database to December 2008. Randomized controlled trials examining the efficacy of the administration of psychotherapy after successful response to acute-phase pharmacotherapy in the treatment of adults with MDD were considered for inclusion in the meta-analysis.

RESULTS

Eight high-quality studies with 442 patients in a sequential treatment arm and 433 in a control treatment arm were included. The pooled risk ratio (RR) for relapse/recurrence was 0.797 [95% confidence interval (CI) 0.659-0.964] according to the random-effects model, suggesting a relative advantage in preventing relapse/recurrence for the sequential administration of treatments compared with control conditions. Performing subgroup analyses, we found a trend favoring psychotherapy during continuation of antidepressant drugs compared to antidepressants or treatment as usual (RR 0.842, 95% CI 0.674-1.051). Patients randomized to psychotherapy while antidepressants were discontinued were significantly less likely to experience relapse/recurrence compared to controls (RR 0.650, 95% CI 0.463-0.912).

CONCLUSIONS

We found evidence that the sequential integration of psychotherapy and pharmacotherapy is a viable strategy for preventing relapse and recurrence in MDD. In addition, our findings suggest that discontinuation of antidepressant drugs may be feasible when psychotherapy is provided.

Disrupting the rhythm of depression using Mobile Cognitive Therapy for recurrent depression: randomized controlled trial design and protocol

BACKGROUND

Major depressive disorder (MDD) is projected to rank second on a list of 15 major diseases in terms of burden in 2030. The major contribution of MDD to disability and health care costs is largely due to its highly recurrent nature. Accordingly, efforts to reduce the disabling effects of this chronic condition should shift to preventing recurrence, especially in patients at high risk of recurrence. Given its high prevalence and the fact that interventions are necessary during the remitted phase, new approaches are needed to prevent relapse in depression.

METHODS/DESIGN

The best established effective and available psychological intervention is cognitive therapy. However, it is costly and not available for most patients. Therefore, we will compare the effectiveness and cost-effectiveness of self-management supported by online CT accompanied by SMS based tele-monitoring of depressive symptomatology, i.e. Mobile Cognitive Therapy (M-CT) versus treatment as us usual (TAU). Remitted patients (n = 268) with at least two previous depressive episodes will be recruited and randomized over (1) M-CT in addition to TAU versus (2) TAU alone, with follow-ups at 3, 12, and 24 months. Randomization will be stratified for number of previous episodes and type of treatment as usual. Primary outcome is time until relapse/recurrence over 24 months using DSM-IV-TR criteria as assessed by the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID). For the economic evaluation the balance between costs and health outcomes will be compared across strategies using a societal perspective.

DISCUSSION

Internet-based interventions might be helpful in empowering patients to become their own disease managers in this lifelong recurrent disorder. This is, as far as we are aware of, the first study that examines the (cost) effectiveness of an E-mental health program using SMS monitoring of symptoms with therapist support to prevent relapse in remitted recurrently depressed patients.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR2503.

Disrupting the rhythm of depression: design and protocol of a randomized controlled trial on preventing relapse using brief cognitive therapy with or without antidepressants

BACKGROUND

Maintenance treatment with antidepressants is the leading strategy to prevent relapse and recurrence in patients with recurrent major depressive disorder (MDD) who have responded to acute treatment with antidepressants (AD). However, in clinical practice most patients (up to 70-80%) are not willing to take this medication after remission or take too low dosages. Moreover, as patients need to take medication for several years, it may not be the most cost-effective strategy. The best established effective and available alternative is brief cognitive therapy (CT). However, it is unclear whether brief CT while tapering antidepressants (AD) is an effective alternative for long term use of AD in recurrent depression. In addition, it is unclear whether the combination of AD to brief CT is beneficial.

METHODS/DESIGN

Therefore, we will compare the effectiveness and cost-effectiveness of brief CT while tapering AD to maintenance AD and the combination of CT with maintenance AD. In addition, we examine whether the prophylactic effect of CT was due to CT tackling illness related risk factors for recurrence such as residual symptoms or to its efficacy to modify presumed vulnerability factors of recurrence (e.g. rigid explicit and/or implicit dysfunctional attitudes). This is a multicenter RCT comparing the above treatment scenarios. Remitted patients on AD with at least two previous depressive episodes in the past five years (n = 276) will be recruited. The primary outcome is time related proportion of depression relapse/recurrence during minimal 15 months using DSM-IV-R criteria as assessed by the Structural Clinical Interview for Depression. Secondary outcome: economic evaluation (using a societal perspective) and number, duration and severity of relapses/recurrences.

DISCUSSION

This will be the first trial to investigate whether CT is effective in preventing relapse to depression in recurrent depression while tapering antidepressant treatment compared to antidepressant treatment alone and the combination of both. In addition, we explore explicit and implicit mediators of CT.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR1907.

Influence of comorbidity with depression on interdisciplinary therapy: outcomes in patients with chronic low back pain

INTRODUCTION

Our previous work showed higher tumour necrosis factor (TNF)-α levels in patients with chronic low back pain (cLBP) compared to healthy controls. However, patients with depression as a comorbidity did not have higher TNF-α levels in comparison to patients without depression. In this study we investigated the influence of depression on therapy outcomes such as TNF-α serum levels, pain intensity and back function in patients with cLBP. Our hypothesis was that patients with both cLBP and depression benefit no less than patients with cLBP alone from the multidisciplinary pain therapy.

METHODS

A total of 58 patients with cLBP alone or with both cLBP and depression were age- and sex-matched with 29 healthy controls. Serum concentrations of TNF-α were assayed at the beginning of the study (T0) and 10 days (T1), 21 days (T2), and 180 days (T3) later. The clinical outcomes such as pain intensity, as well as back function, sleep, exercise, alcohol and nicotine consumption were documented. In the first three weeks, all patients underwent multidisciplinary therapy based upon biological, psychological, physical and psychosocial components.

RESULTS

Over the whole course there were no differences in TNF-α level between cLBP patients with and without depression. At T0, both cLBP patients with (cLBP+DE) and without (cLBP) depression showed significantly higher TNF-α serum levels (P = 0.002 for cLBP+DE, P = 0.004 for cLBP) than healthy controls (HC) that normalized after 10 days of therapy and remained similar to healthy controls. During the follow-up, the depression scales were normalised and pain intensity was significantly reduced. Both evidences processed parallel to the reduction of TNF-α levels, which correlates neither with depression score nor with pain intensity at any time point.

CONCLUSIONS

Depression as a comorbidity to chronic low back pain did not influence the serum TNF-α level in the course of six months, but seemed to affect the success of therapy. cLBP patients with comorbidity of depression benefit from multidisciplinary pain therapy not only to the same extent but also to a greater degree than cLBP patients without depression.

Unipolar depression: diagnostic and therapeutic recommendations from the current S3/National Clinical Practice Guideline

BACKGROUND

Depressive disorders are among the most common illnesses and reasons for obtaining health care. Their diagnosis and treatment are still in need of improvement. In Germany, a new S3/National Clinical Practice Guideline has been developed for this purpose.

METHODS

The existing guidelines on unipolar depression from Germany and other countries were synoptically compared and supplemented with systematic literature searches. After 14 consensus conferences, a total of 107 evidence-based recommendations were issued.

RESULTS

Unipolar depression should be diagnosed in accordance with ICD-10 criteria. Screening questionnaires are useful aids to diagnostic classification. When a treatment is chosen, shared decision-making with the patient is essential. Mild depressive episodes can be treated initially by watchful waiting for 14 days. For moderate depressive episodes, pharmacotherapy and psychotherapy are equally effective treatment options. For severe depression, a combination of pharmacotherapy and psychotherapy is recommended. If 4 to 6 weeks of acute therapy are insufficiently effective, lithium augmentation is recommended, rather than combination antidepressant therapy or a switch to another antidepressant. After remission, maintenance therapy should be continued for 4 to 9 months. In recurrent depression, pharmacotherapy and/or psychotherapy, where appropriate, should be continued for at least two years. Specific recommendations are given for patients who have somatic or mental comorbidities or are acutely suicidal, and recommendations are also given for coordination of care.

CONCLUSION

This guideline is a comprehensive set of evidence- and consensus-based recommendations for the diagnosis and treatment of unipolar depression. An improvement in the care of patients with unipolar depression will require broad implementation of the guideline, both in the inpatient and outpatient setting.

Die Rolle der Übungshäufigkeit in der Achtsamkeitsbasierten Kognitiven Therapie

Zusammenfassung. Theoretischer Hintergrund: Der Übungshäufigkeit wird im Rahmen der Mindfulness-Based Cognitive Therapy (MBCT) eine große Bedeutung zugeschrieben. Fragestellung: Üben MBCT-Patienten den Vorgaben entsprechend und weisen Patienten, die häufiger üben, ein geringeres Rückfallrisiko auf? Methoden: Die Übungshäufigkeit der 24 ehemals depressiven Patienten wurde direkt nach der MBCT sowie nach 6 und 12 Monaten erhoben. Rückfälle wurden 12 Monate nach Ende der Behandlung erfasst. Ergebnisse: Während des MBCT-Programms übten die Patienten weitgehend den Vorgaben entsprechend. Patienten, die nicht rückfällig wurden, übten in den sechs Monaten nach Behandlungsende den Bodyscan und die Meditation signifikant häufiger als Patienten, die einen Rückfall erleiden. Schlussfolgerungen: Es konnte ein erster Hinweis für die Relevanz der Übungshäufigkeit bezüglich der Wirksamkeit der MBCT gefunden werden.

Cognitive behavioral therapy for mood disorders: efficacy, moderators and mediators

Cognitive behavioral therapy (CBT) is efficacious in the acute treatment of depression and may provide a viable alternative to antidepressant medication (ADM) for even more severely depressed unipolar patients when implemented in a competent fashion. CBT also may be of use as an adjunct to medication treatment of bipolar patients, although there have been few studies and they are not wholly consistent. CBT does seem to have an enduring effect that protects against subsequent relapse and recurrence following the end of active treatment, which is not the case for medications. Single studies that require replication suggest that patients who are married or unemployed or who have more antecedent life events may do better in CBT than in ADM, as might patients who are free from comorbid Axis II disorders, whereas patients with comorbid Axis II disorders seem to do better in ADM than in CBT. There also are indications that CBT may work through processes specified by theory to produce change in cognition that in turn mediate subsequent change in depression and freedom from relapse following treatment termination, although evidence in that regard is not yet conclusive.

Comparative efficacy and durability of continuation phase cognitive therapy for preventing recurrent depression: design of a double-blinded, fluoxetine- and pill placebo-controlled, randomized trial with 2-year follow-up

BACKGROUND

Major Depressive Disorder (MDD) is highly prevalent and associated with disability and chronicity. Although cognitive therapy (CT) is an effective short-term treatment for MDD, a significant proportion of responders subsequently suffer relapses or recurrences.

PURPOSE

This design prospectively evaluates: 1) a method to discriminate CT-treated responders at lower vs. higher risk for relapse; and 2) the subsequent durability of 8-month continuation phase therapies in randomized higher risk responders followed for an additional 24 months. The primary prediction is: after protocol treatments are stopped, higher risk patients randomly assigned to continuation phase CT (C-CT) will have a lower risk of relapse/recurrence than those randomized to fluoxetine (FLX).

METHODS

Outpatients, aged 18 to 70 years, with recurrent MDD received 12-14 weeks of CT provided by 15 experienced therapists from two sites. Responders (i.e., no MDD and 17-item Hamilton Rating Scale for Depression

RESULTS

The trial began in 2000. Enrollment is complete (n=523). The follow-up continues.

CONCLUSIONS

The trial evaluates the preventive effects and durability of acute and continuation phase treatments in the largest known sample of CT responders collected worldwide.

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Key Words

• relapse prevention
• recurrent depression
• cognitive therapy
• fluoxetine
• longitudinal follow-up

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MESH Headings

• Adolescent
• Adult
• Aged
• Antidepressive Agents, Second-Generation/therapeutic use
• Cognitive Behavioral Therapy
• Depressive Disorder, Major/prevention & control
• Depressive Disorder, Major/therapy
• Double-Blind Method
• Female
• Fluoxetine/therapeutic use
• Follow-Up Studies
• Humans
• Male
• Middle Aged
• Research Design
• Secondary Prevention
• Young Adult

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Grants

• K24 MH001571 NIMH NIH HHS
• K24-MH001571 NIMH NIH HHS
• R01 MH-58356 NIMH NIH HHS
• R01 MH058397 NIMH NIH HHS
• R01 MH069618 NIMH NIH HHS
• R01 MH058397-11 NIMH NIH HHS
• R01 MH-69219 NIMH NIH HHS
• R01 MH-58397 NIMH NIH HHS
• R01 MH069619-05 NIMH NIH HHS
• R01 MH-69618 NIMH NIH HHS
• L40 MH069219 NIMH NIH HHS
• R01 MH069619 NIMH NIH HHS
• R01 MH058356 NIMH NIH HHS
• K24 MH001571-10 NIMH NIH HHS

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Affiliation(s)

Robin B. Jarrett Department of Psychiatry, The University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX, 75390-9149, United States of America; 214-648-5345; fax 214-648-5340
Michael E. Thase The University of Pennsylvania School of Medicine, 3535 Market Street, Suite 670, Philadelphia, PA, 19104, United States of America. Philadelphia, Veterans Affairs Medical Center and University of Pittsburgh Medical Center

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Identifying target groups for the prevention of anxiety disorders in the general population

OBJECTIVE

To avert the public health consequences of anxiety disorders, prevention of their onset and recurrence is necessary. Recent studies have shown that prevention is effective. To maximize the health gain and minimize the effort, preventive strategies should focus on high-risk groups.

METHOD

Using data from a large prospective national survey, high-risk groups were selected for i) the prevention of first ever (n = 4437) and ii) either first-ever or recurrent incident anxiety disorders (n = 4886). Indices used were: exposure rate, odds ratio, population attributable fraction and number needed to be treated. Risk indicators included sociodemographic, psychological and illness-related factors.

RESULTS

Recognition of a few patient characteristics enables efficient identification of high-risk groups: (subthreshold) panic attacks; an affective disorder; a history of depressed mood; a prior anxiety disorder; chronic somatic illnesses and low mastery.

CONCLUSION

Preventive efforts should be undertaken in the selected high-risk groups.

New modalities of assessment and treatment planning in depression: the sequential approach

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.

The long-term effects of mindfulness-based cognitive therapy as a relapse prevention treatment for major depressive disorder

BACKGROUND

Mindfulness-based Cognitive Therapy (MBCT) is a relapse prevention treatment for major depressive disorder.

METHOD

An observational clinical audit of 39 participants explored the long-term effects of MBCT using standardized measures of depression (BDI-II), rumination (RSS), and mindfulness (MAAS).

RESULTS

MBCT was associated with statistically significant reductions in depression from pre to post treatment. Gains were maintained over time (Group 1, 1-12 months, p = .002; Group 2, 13-24 months, p = .001; Group 3, 25-34 months, p = .04). Depression scores in Group 3 did begin to worsen, yet were still within the mild range of the BDI-II. Treatment variables such as attendance at "booster" sessions and ongoing mindfulness practice correlated with better depression outcomes (p = .003 and p = .03 respectively). There was a strong negative correlation between rumination and mindful attention (p < .001), consistent with a proposed mechanism of metacognition in the efficacy of MBCT.

CONCLUSION

It is suggested that ongoing MBCT skills and practice may be important for relapse prevention over the longer term. Larger randomized studies of the mechanisms of MBCT with longer follow-up periods are recommended.

Moderators of continuation phase cognitive therapy's effects on relapse, recurrence, remission, and recovery from depression

About half of patients who respond to acute-phase cognitive therapy (CT) for major depressive disorder (MDD) will relapse/recur within 2 years; continuation-phase CT lowers this risk. We analyzed demographic, clinical, cognitive, social-interpersonal, and personality variables to clarify which patients continuation-phase CT helps to avoid relapse and recurrence and achieve remission and recovery. Participants had recurrent MDD, responded to acute-phase CT, were randomized to 8 months of continuation-phase CT (n = 41) or assessment control (n = 43), and were assessed 16 additional months (Jarrett et al., 2001). Consistent with an underlying risk-reduction model, continuation-phase CT was helpful for responders to acute-phase CT with greater risk and/or dysfunction as follows: Younger patients with earlier MDD onset who displayed greater dysfunctional attitudes and lower self-efficacy; personality traits suggesting low positive activation (e.g., reduced energy, enthusiasm, gregariousness); and transiently elevated depressive symptoms late in acute-phase CT and residual symptoms after acute-phase CT response. We emphasize the need for replication of these results before clinical application.

Cognitive behavioural therapy for major psychiatric disorder: does it really work? A meta-analytical review of well-controlled trials

BACKGROUND

Although cognitive behavioural therapy (CBT) is claimed to be effective in schizophrenia, major depression and bipolar disorder, there have been negative findings in well-conducted studies and meta-analyses have not fully considered the potential influence of blindness or the use of control interventions.

METHOD

We pooled data from published trials of CBT in schizophrenia, major depression and bipolar disorder that used controls for non-specific effects of intervention. Trials of effectiveness against relapse were also pooled, including those that compared CBT to treatment as usual (TAU). Blinding was examined as a moderating factor.

RESULTS

CBT was not effective in reducing symptoms in schizophrenia or in preventing relapse. CBT was effective in reducing symptoms in major depression, although the effect size was small, and in reducing relapse. CBT was ineffective in reducing relapse in bipolar disorder.

CONCLUSIONS

CBT is no better than non-specific control interventions in the treatment of schizophrenia and does not reduce relapse rates. It is effective in major depression but the size of the effect is small in treatment studies. On present evidence CBT is not an effective treatment strategy for prevention of relapse in bipolar disorder.

Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication

BACKGROUND

In 2001, the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT) partnered to produce evidence-based clinical guidelines for the treatment of depressive disorders. A revision of these guidelines was undertaken by CANMAT in 2008-2009 to reflect advances in the field. This article, one of five in the series, reviews new studies of psychotherapy in the acute and maintenance phase of MDD, including computer-based and telephone-delivered psychotherapy.

METHODS

The CANMAT guidelines are based on a question-answer format to enhance accessibility to clinicians. Evidence-based responses are based on updated systematic reviews of the literature and recommendations are graded according to the Level of Evidence, using pre-defined criteria. Lines of Treatment are identified based on criteria that included evidence and expert clinical support.

RESULTS

Cognitive-Behavioural Therapy (CBT) and Interpersonal Therapy (IPT) continue to have the most evidence for efficacy, both in acute and maintenance phases of MDD, and have been studied in combination with antidepressants. CBT is well studied in conjunction with computer-delivered methods and bibliotherapy. Behavioural Activation and Cognitive-Behavioural Analysis System of Psychotherapy have significant evidence, but need replication. Newer psychotherapies including Acceptance and Commitment Therapy, Motivational Interviewing, and Mindfulness-Based Cognitive Therapy do not yet have significant evidence as acute treatments; nor does psychodynamic therapy.

LIMITATIONS

Although many forms of psychotherapy have been studied, relatively few types have been evaluated for MDD in randomized controlled trials. Evidence about the combination of different types of psychotherapy and antidepressant medication is also limited despite widespread use of these therapies concomitantly.

CONCLUSIONS

CBT and IPT are the only first-line treatment recommendations for acute MDD and remain highly recommended for maintenance. Both computer-based and telephone-delivered psychotherapy--primarily studied with CBT and IPT--are useful second-line recommendations. Where feasible, combined antidepressant and CBT or IPT are recommended as first-line treatments for acute MDD.

Continuation-phase cognitive therapy's effects on remission and recovery from depression

The authors tested the effects of continuation-phase cognitive therapy (C-CT) on remission and recovery from recurrent major depressive disorder, defined as 6 weeks and 8 months, respectively, of continuously absent or minimal symptoms. Responders to acute-phase cognitive therapy were randomized to 8 months of C-CT (n = 41) or assessment control (n = 43), and they were followed 16 additional months (R. B. Jarrett et al., 2001). Relative to controls, a few more patients in C-CT remitted (88% vs. 97%), and significantly more recovered (62% vs. 84%). All patients without remission and recovery relapsed, but most patients who remitted (60%) and who recovered (75%) did not later relapse or recur. The authors discuss the importance of defining efficacious treatment as producing remission and recovery.

[Affective disorders. The significance of psychotherapeutic approaches]

The use of psychotherapeutic strategies is essential in the treatment of affective disorders. Psychotherapy proved to be at least equivalent to antidepressant medication in the treatment of mild to moderate depression. In severe cases, the combination of both treatments is considered by guidelines to be the standard treatment. Psychotherapeutic approaches show a longer latency than antidepressants; however, the effects are longer lasting. Regarding the effectiveness of pharmacotherapy sobering results have been published recently. Therefore, the further development of psychotherapy deserves special attention. Cognitive behavioral therapy and interpersonal therapy provide the highest evidence. The empirical basis for psychodynamic psychotherapies is still limited. In the treatment of chronic depression a new approach--cognitive behavioral analysis system of psychotherapy--is gaining importance. There is a trend towards an increasing specification of psychotherapy for distinct subgroups of depressed patients. Challenges for the future include increasing treatment efficacy, investigating mechanisms of efficacy and predictors for a differential indication, and making effective approaches generally available to all patients.

Adherence to continuation and maintenance antidepressant use in recurrent depression

BACKGROUND

In chronic diseases adherence is a problem. Little is known about adherence to antidepressants after the acute phase in recurrent depression. This study evaluates adherence to antidepressants in the continuation and maintenance phase in remitted recurrently depressed patients.

METHODS

We prospectively assessed adherence to continuation and maintenance antidepressant use, the longest phase in antidepressant treatment, over 2 years and the association of adherence with future recurrence in 131 recurrently depressed patients remitted on antidepressants.

LIMITATIONS

Self reported non-adherence.

RESULTS

Non-adherence ranged from 39.7% to 52.7%; 20.9% were always non-adherent, 48.4% were intermittently non-adherent and 30.8% were always adherent. Adherence rates did not significantly differ between intermittent and continuous antidepressant users (37.2% vs. 25%). Non-adherence predicted time to recurrence.

CONCLUSION

Non-adherence to continuation and maintenance antidepressant treatment in recurrent depression is frequent, like in other chronic diseases, and a potential risk of recurrence. Doctors continuously have to be aware of this problem and should keep on discussing it with their patients. Finally, as many patients don't seem to be able or willing to take AD as prescribed, alternatives to prevent relapse deserve more attention.

How many well vs. unwell days can you expect over 10 years, once you become depressed?

OBJECTIVE

Prognostic studies of major depression have mainly focused on episode remission and relapse, and only a limited number of studies have examined long-term course of depressive symptomatology at threshold and subthreshold levels.

METHOD

The Group for Longitudinal Affective Disorders Study has conducted prospective serial assessments of a cohort of heretofore untreated major depressive episodes for 10 years under naturalistic conditions.

RESULTS

Of the 94 patients in the cohort, the follow-up rate was 70% of the 11,280 person-months. Around 77% of the follow-up months were spent in euthymia, 16% in subthreshold depression and 7% in major depression. Duration of the index episode before reaching recovery was the only significant predictor of the ensuing well time.

CONCLUSION

On average, patients with major depression starting treatment today may expect to spend three quarters of the next decade in euthymia but the remaining one quarter in subthreshold or threshold depression.

Deterioration in psychosocial functioning predicts relapse/recurrence after cognitive therapy for depression

BACKGROUND

Associations between major depressive disorder (MDD) and psychosocial functioning are incompletely understood across time and during continuation phase cognitive therapy (C-CT). We examined the validity of the Range of Impaired Functioning Tool (RIFT; [Leon, A.C., Solomon, D.A., Mueller, T.I., Turvey, C.L., Endicott, J., Keller, M.B., 1999. The Range of Impaired Functioning Tool (LIFE-RIFT): A brief measure of functional impairment. Psychol. Med. 29, 869-878.]) as a measure of psychosocial functioning and its relations to depressive symptoms in C-CT and assessment-only control conditions.

METHODS

Outpatients with recurrent MDD who responded to acute-phase cognitive therapy (A-CT) were randomized to 8 months of C-CT (n=41) or assessment-only (n=43) and followed 16 additional months [Jarrett, R.B., Kraft, D., Doyle, J., Foster, B.M., Eaves, G.G., Silver, P.C., 2001. Preventing recurrent depression using cognitive therapy with and without a continuation phase: A randomized clinical trial. Arch. Gen. Psychiatry 58, 381-388.]. Interviewers rated depressive symptoms and psychosocial functioning monthly. Patients completed additional self-reports.

RESULTS

The RIFT converged appropriately with other measures of psychosocial functioning, depressive symptoms, cognitive content, and personality. About half (55%) of patients were psychosocially "well" (RIFT< or =8) during the first month post-A-CT. C-CT improved psychosocial functioning only transiently compared to the assessment control. Examined prospectively, depressive symptom level did not predict monthly changes in psychosocial functioning significantly, whereas psychosocial dysfunction level predicted monthly changes in depressive symptoms and relapse/recurrence.

LIMITATIONS

Findings may not generalize to other patient populations, treatments, and assessment methods. The cross-lagged correlational data structure allows only tentative conclusions about the causal effect of psychosocial functioning on depressive symptoms.

CONCLUSIONS

The RIFT is a valid measure of psychosocial functioning among responders to A-CT for depression. After such response, deteriorations in psychosocial functioning may signal imminent major depressive relapse/recurrence and provide targets for change during treatments focused on relapse/recurrence prevention.