Specificity of CBT for Depression: A Contribution from Multiple Treatments Meta-analyses

Differences in Children and Adolescents with Depression before and after a Remediation Program: An Event-Related Potential Study

Depression is clinically diagnosed when a defined constellation of symptoms manifests over a specific duration with notable severity. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), Major Depressive Disorder (MDD) is characterized by the presence of five or more symptoms persisting for at least two weeks. As a profound mental health condition affecting millions globally, depression presents a considerable challenge for researchers and clinicians alike. In pediatric and adolescent populations, depression can precipitate adverse outcomes, including substance abuse, academic difficulties, risky sexual behaviors, physical health problems, impaired social relationships, and a markedly elevated risk of suicide-up to thirty times higher than the general population. This paper details a study that evaluated the efficacy of Cognitive Behavioral Therapy (CBT) alone vs. CBT combined with selective serotonin reuptake inhibitors (SSRIs) in a treatment program. The study cohort comprised sixteen (16) children and adolescents diagnosed with depression (eight males and eight females) and sixteen (16) typically developing peers (eight males and eight females) aged from 9 to 15 years (Mean age = 11.94, standard deviation = 2.02). Initial assessments employed Event-Related Potentials (ERPs), the Children's Depression Inventory (CDI), and reaction time measurements. The results reveal that participants with depression exhibit cognitive deficits in attention and memory, as evidenced by prolonged P300 latencies. Following intervention with either CBT alone or CBT combined with medication, the depressed participants demonstrated significant improvements, evidenced by lower CDI scores, reduced P300 latencies, and faster reaction times, both compared to their pre-treatment status and relative to the control group.

Network meta-analysis in psychology and educational sciences: A systematic review of their characteristics

Network meta-analysis (NMA) allows the combination of evidence on the effectiveness of several interventions. NMA has mainly been applied in the medical science field, whereas in the domain of psychology and educational sciences its use is less frequent. Consequently, systematic reviews that describe the characteristics of published NMAs are limited to the field of medicine, and nothing is known about the characteristics of NMAs published in the psychology and educational sciences field. However, this information is still relevant for the design of future simulation studies and for detecting good and bad research practices. Thus, this study describes the features of the meta-analytic datasets of NMAs published in the field of psychology and educational sciences, as well as their methodological characteristics, and compares them to those observed in the medical domain. Results show that the number of studies included is larger in NMAs from psychology and educational sciences, the most commonly used effect size is the standardized mean difference (unlike the odds ratio in medicine), the sample size is smaller, more intervention groups are included, and inconsistent effects are observed more often. These results can be used in future simulation studies to generate realistic datasets. Finally, we warn about the poor quality of reporting of some technical aspects of the NMA, such as the statistical model used.

Pharmacological and Psychotherapeutic Interventions for Management of Obsessive-compulsive Disorder in Adults: A Systematic Review and Network Meta-analysis

Reprinted under Creative Commons CC-BY license.

Top-down causation in psychiatric disorders: a clinical-philosophical inquiry

Psychiatry has long debated whether the causes of mental illness can be better explained by reductionist or pluralistic accounts. Although the former relies on commonsense scientific bottom-up causal models, the latter (which typically include environmental, psychological, and/or socio-cultural risk factors) requires top-down causal processes often viewed with skepticism, especially by neuroscientists. We begin with four clinical vignettes which illustrate self-interventions wherein high-order psychological processes (e.g. religious beliefs or deep interpersonal commitments) appear to causally impact the risk for or the course of psychiatric/behavioral disorders. We then propose a model for how to understand this sort of top-down self-causation. Our model relies centrally on the concept of a control variable which, like a radio tuning dial, can implement a series of typically unknown physical processes to obtain the desired ends. We set this control variable in the context of an interventionist account of causation that assumes that a cause (C) produces an effect (E) when intervening on C (by manipulating it) is associated with a change in E. We extend this framework by arguing that certain psychological changes can result from individuals intervening on their own mental states and/or selection of environments. This in turn requires a conception of the self that contains mental capacities that are at least partially independent of one another. Although human beings cannot directly intervene on the neurobiological systems which instantiate risk for psychiatric illness, they can, via control variables at the psychological level, and/or by self-selection into protective environments, substantially alter their own risk.

Towards personalising treatment: a systematic review and meta-analysis of face-to-face efficacy moderators of cognitive-behavioral therapy and interpersonal psychotherapy for major depressive disorder

BACKGROUND

Consistent evidence suggests that face-to-face cognitive-behavioural therapy (CBT) and interpersonal psychotherapy (IPT) may be equally effective depression treatments. Current clinical research focuses on detecting the best predictors-moderators of efficacy to guide treatment personalisation. However, individual moderator studies show inconsistent findings. This systematic review and meta-analysis aimed to compare the efficacy of CBT and IPT, including combined treatment with antidepressants for depression, and evaluate the predictive power of demographic, clinical presentation and treatment characteristics moderators for both therapies.

METHODS

PsycArticles, PsycINFO, PubMed and Cochrane Library were systematically searched through December 2017 for studies that have assessed individuals with major depression receiving either CBT or IPT in a face-to-face format both at pre- and post-treatment. Random-effects moderator meta-analyses were conducted.

RESULTS

In total 168 samples from 137 studies including 11 374 participants qualified for the meta-analytic review. CBT and IPT were equally effective across all but one prespecified moderators. For psychotherapy delivered without concomitant antidepressant treatment [antidepressant medications (ADMs)], CBT was superior to IPT (g = 1.68, Qbetweenp = 0.037). Within-CBT moderator analyses showed that increased CBT efficacy was associated with lower age, high initial depression severity, individual format of administration and no adjunctive ADMs. Within-IPT analyses showed comparable efficacy across all moderators.

CONCLUSIONS

Clinical guidance around combined treatment (psychotherapy plus ADMs) should be reconsidered. CBT alone is superior to IPT alone and to combined treatment, while IPT alone is non-inferior to combined treatment. More research is needed to assess the moderating effect of older age and number of previous episodes on IPT efficacy.

Is psychotherapy effective? A re-analysis of treatments for depression

AimsThe aim of this study was to reanalyse the data from Cuijpers et al.'s (2018) meta-analysis, to examine Eysenck's claim that psychotherapy is not effective. Cuijpers et al., after correcting for bias, concluded that the effect of psychotherapy for depression was small (standardised mean difference, SMD, between 0.20 and 0.30), providing evidence that psychotherapy is not as effective as generally accepted.

METHODS

The data for this study were the effect sizes included in Cuijpers et al. (2018). We removed outliers from the data set of effects, corrected for publication bias and segregated psychotherapy from other interventions. In our study, we considered wait-list (WL) controls as the most appropriate estimate of the natural history of depression without intervention.

RESULTS

The SMD for all interventions and for psychotherapy compared to WL controls was approximately 0.70, a value consistent with past estimates of the effectiveness of psychotherapy. Psychotherapy was also more effective than care-as-usual (SMD = 0.31) and other control groups (SMD = 0.43).

CONCLUSIONS

The re-analysis reveals that psychotherapy for adult patients diagnosed with depression is effective.

"Gold Standards," Plurality and Monocultures: The Need for Diversity in Psychotherapy

For psychotherapy of mental disorders, presently several approaches are available, such as interpersonal, humanistic, systemic, psychodynamic or cognitive behavior therapy (CBT). Pointing to the available evidence, proponents of CBT claim that CBT is the gold standard. Some authors even argue for an integrated CBT-based form of psychotherapy as the only form of psychotherapy. CBT undoubtedly has its strengths and CBT researchers have to be credited for developing and testing treatments for many mental disorders. A critical review, however, shows that the available evidence for the theoretical foundations of CBT, assumed mechanisms of change, quality of studies, and efficacy is not as robust as some researchers claim. Most important, there is no consistent evidence that CBT is more efficacious than other evidence-based approaches. These findings do not justify regarding CBT as the gold standard psychotherapy. They even provide less justification for the idea that the future of psychotherapy lies in one integrated CBT-based form of psychotherapy as the only type of psychotherapy. For the different psychotherapeutic approaches a growing body of evidence is available. These approaches have their strengths because of differences in their respective focus on interpersonal relationships, affects, cognitions, systemic perspectives, experiential, or unconscious processes. Different approaches may be suitable to different patients and therapists. As generally assumed, progress in research results from openness to new ideas and learning from diverse perspectives. Thus, different forms of evidence-based psychotherapy are required. Plurality is the future of psychotherapy, not a uniform "one fits all" approach.

Inclusion and exclusion strategies for conducting meta-analyses

Some of the most important decisions that a researcher will make when conducting a meta-analysis are decisions about the search strategies and inclusion/exclusion criteria. Decisions regarding inclusion/exclusion criteria serve to define the scope of a meta-analysis and search strategy decisions can have a large impact on how well the results of a meta-analysis actually represent the existing body of literature. In this article, we provide descriptions and recommendations for performing searches and making inclusion/exclusion decisions. We also provide a review of 65 meta-analyses of psychotherapy versus pharmacotherapy in order to offer frequency data on the use of various search strategies and inclusion/exclusion decisions in the field.

Examining the relationship between encouragement and health-related quality of life among Muslims

This study examines the relationship between encouragement and health-related quality of life (HRQOL) among a sample of American Muslims, in tandem with the potential mediating effects of depression and spirituality. To conduct this cross-sectional study, a model was developed and tested using structural equation modeling (SEM) with a community sample of Muslims (N = 284). The results indicate that encouragement has a direct, positive effect on HRQOL. Neither depression nor spirituality mediated the relationship between encouragement and HRQOL. Rather, both variables exhibited a direct, independent effect on HRQOL. In addition, spirituality exhibited an indirect effect on HRQOL through attenuating depression. The findings underscore the importance of encouragement as a pathway to enhance HRQOL among Muslims in post-9/11 America. The results also suggest that spirituality can play a significant role in fostering HRQOL among Muslims, both directly and indirectly by reducing the effects of depression on HRQOL.

The Effect of Guided Web-Based Cognitive Behavioral Therapy on Patients With Depressive Symptoms and Heart Failure: A Pilot Randomized Controlled Trial

Background

Depressive symptoms, and the associated coexistence of symptoms of anxiety and decreased quality of life (QoL), are common in patients with heart failure (HF). However, treatment strategies for depressive symptoms in patients with HF still remain to be established. Internet-based cognitive behavioral therapy (ICBT), as guided self-help CBT programs, has shown good effects in the treatment of depression. Until now, ICBT has not been evaluated in patients with HF with depressive symptoms.

Objective

The aims of this study were to (1) evaluate the effect of a 9-week guided ICBT program on depressive symptoms in patients with HF; (2) investigate the effect of the ICBT program on cardiac anxiety and QoL; and (3) assess factors associated with the change in depressive symptoms.

Methods

Fifty participants were randomized into 2 treatment arms: ICBT or a Web-based moderated discussion forum (DF). The Patient Health Questionnaire-9 was used to measure depressive symptoms, the Cardiac Anxiety Questionnaire (CAQ) was used to measure cardiac-related anxiety, and the Minnesota Living with Heart Failure questionnaire was used to measure QoL. Data were collected at baseline and at follow-up at the end of the 9-week intervention. Intention-to-treat analysis was used, and missing data were imputed by the Expectation-Maximization method. Between-group differences were determined by analysis of covariance with control for baseline score and regression to the mean.

Results

No significant difference in depressive symptoms between the ICBT and the DF group at the follow-up was found, [F(1,47)=1.63, P=.21] and Cohen´s d=0.26. Secondary within-group analysis of depressive symptoms showed that such symptoms decreased significantly in the ICBT group from baseline to the follow-up (baseline M=10.8, standard deviation [SD]=5.7 vs follow-up M=8.6, SD=4.6, t(24)=2.6, P=.02, Cohen´s d=0.43), whereas in the DF group, there was no significant change (baseline M=10.6, SD=5.0, vs follow-up M=9.8, SD=4.3, t(24)=0.93, P=.36. Cohen´s d=0.18). With regard to CAQ and QoL no significant differences were found between the groups (CAQ [d(1,47)=0.5, P=.48] and QoL [F(1,47)=2.87, P=.09]). In the ICBT group in the CAQ subscale of fear, a significant within-group decrease was shown (baseline M=1.55 vs follow-up M=1.35, P=.04). In the ICBT group, the number of logins to the Web portal correlated significantly with improvement in depressive symptoms (P=.02), whereas higher age (P=.01) and male sex (P=.048) were associated with less change in depressive symptoms. This study is underpowered because of difficulties in the recruitment of patients.

Conclusions

Guided ICBT adapted for persons with HF and depressive symptoms was not statistically superior to participation in a Web-based DF. However, within the ICBT group, a statically significant improvement of depressive symptoms was detected.

ClinicalTrial

Clinicaltrials.gov NCT01681771; https://clinicaltrials.gov/ct2/show/NCT01681771 (Archived by WebCite at http://www.webcitation.org/6ikzbcuLN)

Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: a systematic review and network meta-analysis

BACKGROUND

Several interventions are available for management of obsessive-compulsive disorder in adults, but few studies have compared their relative efficacy in a single analysis. We aimed to simultaneously compare all available treatments using both direct and indirect data.

METHODS

In this systematic review and network meta-analysis, we searched the two controlled trials registers maintained by the Cochrane Collaboration Common Mental Disorders group for trials published up to Feb 16, 2016. We selected randomised controlled trials in which an active psychotherapeutic or pharmacological intervention had been used in adults with obsessive-compulsive disorder. We allowed all comorbidities except for schizophrenia or bipolar disorder. We excluded studies that focused exclusively on treatment-resistant patient populations defined within the same study. We extracted data from published reports. The primary outcome was symptom severity as measured by the Yale-Brown Obsessive Compulsive Scale. We report mean differences with 95% credible intervals compared with placebo. This study is registered with PROSPERO, number CRD42012002441.

FINDINGS

We identified 1480 articles in our search and included 53 articles (54 trials; 6652 participants) in the network meta-analysis. Behavioural therapy (mean difference -14·48 [95% credible interval -18·61 to -10·23]; 11 trials and 287 patients), cognitive therapy (-13·36 [-18·40 to -8·21]; six trials and 172 patients), behavioural therapy and clomipramine (-12·97 [-19·18 to -6·74]; one trial and 31 patients), cognitive behavioural therapy and fluvoxamine (-7·50 [-13·89 to -1·17]; one trial and six patients), cognitive behavioural therapy (-5·37 [-9·10 to -1·63]; nine trials and 231 patients), clomipramine (-4·72 [-6·85 to -2·60]; 13 trials and 831 patients), and all SSRIs (class effect -3·49 [95% credible interval -5·12 to -1·81]; 37 trials and 3158 patients) had greater effects than did drug placebo. Clomipramine was not better than were SSRIs (-1·23 [-3·41 to 0·94]). Psychotherapeutic interventions had a greater effect than did medications, but a serious limitation was that most psychotherapeutic trials included patients who were taking stable doses of antidepressants (12 [80%] of the 15 psychotherapy trials explicitly allowed antidepressants).

INTERPRETATION

A range of interventions is effective in the management of obsessive-compulsive disorder, but considerable uncertainty and limitations exist regarding their relative efficacy. Taking all the evidence into account, the combination of psychotherapeutic and psychopharmacological interventions is likely to be more effective than are psychotherapeutic interventions alone, at least in severe obsessive-compulsive disorder.

FUNDING

National Institute for Health Research.

Treatment-as-usual (TAU) is anything but usual: a meta-analysis of CBT versus TAU for anxiety and depression

OBJECTIVES

There were three aims of this study, the first was to examine the efficacy of CBT versus treatment-as-usual (TAU) in the treatment of anxiety and depressive disorders, the second was to examine how TAU is defined in TAU control groups for those disorders, and the third was to explore whether the type of TAU condition influences the estimate of effects of CBT.

METHOD

A systematic search of Cochrane Central Register of Controlled Trials, PsycINFO, and CINAHL was conducted.

RESULTS

48 studies of CBT for depressive or anxiety disorders (n=6926) that specified that their control group received TAU were identified. Most (n=45/48) provided an explanation of the TAU group however there was significant heterogeneity amongst TAU conditions. The meta-analysis showed medium effects favoring CBT over TAU for both anxiety (g=0.69, 95% CI 0.47-0.92, p<0.001, n=1318) and depression (g=0.70, 95% CI 0.49-0.90, p<0.001, n=5054), with differential effects observed across TAU conditions.

CONCLUSIONS

CBT is superior to TAU and the size of the effect of CBT compared to TAU depends on the nature of the TAU condition. The term TAU is used in different ways and should be more precisely described. The four key details to be reported can be thought of as "who, what, how many, and any additional treatments?"