Chronic Depression: Can Cognitive Therapy Succeed When Other Treatments Fail?

FitMindKit: Randomised controlled trial of an automatically tailored online program for mood, anxiety, substance use and suicidality

PURPOSE

Online mental health programs can be effective in reducing symptoms of depression, anxiety disorders, substance use and suicidal ideation. However, most existing e-mental health programs focus on a single domain of mental health, neglecting comorbidity. Furthermore, few programs are tailored to the symptom patterns of the individual user. FitMindKit was designed to overcome the gaps of existing e-mental health programs, providing tailored, transdiagnostic therapeutic content to address a range of comorbid mental health symptoms. A trial was conducted to test the program's efficacy.

METHODS

Australian adults with elevated symptoms of depression, anxiety, suicidal ideation and/or substance use were recruited through social media, with n = 194 randomised into a fully-automated trial of a 10-day brief intervention. Participants were randomly allocated to receive FitMindKit tailored to their symptoms, an untailored generic version of FitMindKit, or an attention control.

RESULTS

Mixed model repeated measures ANOVA indicated that participants in both FitMindKit and the attention control had significant reductions in symptom composite scores. Effects were not significantly greater in the FitMindKit program relative to control, either at post-test or 3-month follow-up. No effects were detected for specific decreases in depression, generalized anxiety, social anxiety, panic, suicidal ideation or alcohol/substance use. There were no significant differences between the tailored and static versions in effectiveness or adherence. Participants in the tailored and static conditions were more satisfied than in the control condition, with some evidence favouring the tailored condition. High attrition reduced power to find effects.

CONCLUSIONS

FitMindKit provides a model for addressing comorbid mental health symptoms in an online program, using automated tailoring to symptom patterns. Modifications to the program are recommended, along with the need for larger trials to test the effects of tailoring on mental health outcomes.

Preferences for Internet-Based Mental Health Interventions in an Adult Online Sample: Findings From an Online Community Survey

BACKGROUND

Despite extensive evidence that Internet interventions are effective in treating mental health problems, uptake of Internet programs is suboptimal. It may be possible to make Internet interventions more accessible and acceptable through better understanding of community preferences for delivery of online programs.

OBJECTIVE

This study aimed to assess community preferences for components, duration, frequency, modality, and setting of Internet interventions for mental health problems.

METHODS

A community-based online sample of 438 Australian adults was recruited using social media advertising and administered an online survey on preferences for delivery of Internet interventions, along with scales assessing potential correlates of these preferences.

RESULTS

Participants reported a preference for briefer sessions, although they recognized a trade-off between duration and frequency of delivery. No clear preference for the modality of delivery emerged, although a clear majority preferred tailored programs. Participants preferred to access programs through a computer rather than a mobile device. Although most participants reported that they would seek help for a mental health problem, more participants had a preference for face-to-face sources only than online programs only. Younger, female, and more educated participants were significantly more likely to prefer Internet delivery.

CONCLUSIONS

Adults in the community have a preference for Internet interventions with short modules that are tailored to individual needs. Individuals who are reluctant to seek face-to-face help may also avoid Internet interventions, suggesting that better implementation of existing Internet programs requires increasing acceptance of Internet interventions and identifying specific subgroups who may be resistant to seeking help.

A group-oriented inpatient CBT programme: a pilot study

The inpatient unit faces many challenges in the effort to deliver comprehensive psychiatric care to acutely ill patients with minimal lengths of stay. Cognitive behaviour therapy (CBT), a structured, problem-focused, time-limited form of treatment has been shown to be a promising intervention with the inpatient population. This paper describes a group-oriented inpatient CBT programme for women and reports pilot data on the experiences of 78 adult female patients. Repeated-measures ANOVAs revealed that participants exhibited improved psychosocial functioning from admission to discharge, with gains maintained at 1 month post-discharge. Partial correlations indicated that participation and engagement in CBT groups is related to improved functioning at discharge. Participants diagnosed with major depressive disorder, bipolar disorder, and psychotic disorders all evidenced similar positive treatment trajectories, suggesting that group-oriented CBT programming may be a useful addition to standard inpatient care.

The Role of Cognitive Behaviour Therapy in Bipolar Disorder

There is increasing support for the use of systematic psychological interventions in combination with pharmacotherapy in the treatment of bipolar disorder (BD). A “manualised” approach, such as cognitive behaviour therapy (CBT), can be used to facilitate adjustment to the disorder, increase the acceptability of prescribed medications and reduce morbidity. This paper outlines psychosocial issues of relevance to individuals with BD and a model to engage individuals in therapy is described. A brief overview is given of some of the interventions that may help sufferers identify and control the acute symptoms of BD, reduce the risk of relapse and improve how they cope with the disorder and its treatment. The available outcome data on the use of CBT and the need for research are also noted.

Abbreviated Cognitive Therapy for Depression: A Pilot Study in Primary Care

There is increasing interest in the use of psychological therapies for depressive disorder in primary care. This paper describes a pilot study using an abbreviated form of cognitive therapy as an adjunctive treatment for major depressive disorder in primary care. Seven primary care patients received an abbreviated cognitive intervention package in addition to their usual treatment. The patients were assessed before and after intervention using observer and self rating measures of depression and their subjective evaluation of the intervention was sought. Four of the subjects showed 50% change in depression ratings at the end of the intervention and only one of the group was taking antidepressant medication. The intervention was generally well accepted by patients and feasible within the time constraints. The initial results are encouraging and a randomized control trial of this brief intervention is now underway.

Cognitive Behaviour Therapy and Depressive Relapse: Justified Optimism or Unwarranted Complacency?

The magnitude of the problem of relapse and recurrence in depression is outlined and it is contended that this is now the major treatment issue facing clinicians. Studies demonstrating a longer term prophylactic effect of Cognitive Behaviour Therapy (CBT) are briefly reviewed and it is concluded that these methods have significantly impacted on relapse rates in unipolar depression. Nevertheless, it is argued that there is little cause for complacency due to the still significant rate of relapse which is found with CBT. While promising cognitive behavioural methods have been developed in the field of addictive disorders, there is a clear need for similar clinical advances in the area of recurrent depression. Some strategies which may have potential for promoting maintenance and preventing relapse are briefly outlined. The importance of developing a coherent model for assessing relapse risk and guiding decisions regarding treatment and after care strategies is emphasized. Lastly, future research directions in this important area are briefly considered.

Cognitive Behaviour Therapy in an In-patient with Chronic Difficulties: A Case Report

It is not clear from the literature whether successful outcomes can be obtained with CBT in chronic, drug refractory patients who require admission to hospital and whose problems date back to childhood. Anecdotal evidence suggests that they can be treated with CBT (e.g. Beck and Freeman, 1990; Young, 1990). However, no detailed reports of successful treatment in this group have been published. The present report will describe the treatment and outcome of one patient, Alison, who was suffering from depression and who was treated with CBT. She had failed to respond to medication and required admission to hospital. She had chronic difficulties that dated back to childhood and had most of the features described by Scott (1992). Her treatment illustrates how the many different aspects of her complex problems could be examined and treated using CBT techniques as these provided a simple way of understanding and dealing with the difficulties she faced.

Ect and Young Minds: Why Choose It?

Comprehensive evaluation of the risks and benefits of applying ECT to young minds would probably not support the practise. This paper explores why some practitioners continue to choose ECT over viable alternative interventions, and argues for improved safeguards against unnecessary and potentially harmful treatments. Ethical decision making must look beyond rapidity of treatment effects, and consider the pros and cons of all available treatments.

Group Cognitive Therapy in Chronic Depression: Results From Two Intervention Studies

This paper describes two interventions used to treat patients suffering with chronic depression. In the first (Study 1), a group of five sufferers from depression of more than one year's duration who had been unresponsive to, or declined drugs were given cognitive therapy for depression in a group format and followed up for a year afterwards. They were compared with a wait-list group with a similar natural history. The treatment group showed greater improvement than the wait list group and maintained most of their gains at follow-up. In the second (Study 2) four patients also suffering from chronic depression who scored highly on the Hollon Severity Index were treated in a cognitive therapy group over a more extended period (28 weeks) using the approach designed to treat personality disorder. Modest gains were made by some patients. The findings are discussed and suggestions for improvement are made.

The effectiveness of psychological treatments for treatment-resistant depression: a systematic review

OBJECTIVE

A systematic review of all studies (controlled and uncontrolled) to evaluate psychological interventions with treatment-resistant depression.

METHOD

A systematic search to identify studies evaluating a psychological intervention with adults with a diagnosis of major depressive disorder who had not responded to at least one course of antidepressant medication.

RESULTS

Twelve studies met inclusion criteria, of which four were controlled and eight uncontrolled. Treatment effect sizes were computable for four studies and ranged from 1.23 to 3.10 with a number of better quality studies demonstrating some improvements in patients following a psychological intervention.

CONCLUSION

Psychological treatments for depression are commonly delivered and often recommended following the failure of medication. The paucity of evidence for their effectiveness in these situations is a significant problem. There is a need for studies with a strong controlled design investigating the effectiveness of psychological treatments for patients with treatment-resistant depression.

Cognitive therapy of depression: pretreatment patient predictors of outcome

This review examines the role of patient predictors of outcome in cognitive therapy of depression. Studies that meet eligibility criteria are reviewed for demonstrated linkage between various predictors (i.e., pretreatment severity, historical features, demographic predictors, dysfunctional attitudes and other cognitive features, and treatment acceptability) and outcome, and several effects are found. Notably, high pretreatment severity scores are associated with poorer response to cognitive therapy, as are high chronicity, younger age at onset, an increased number of previous episodes, and marital status. High pretreatment levels of dysfunctional attitudes and certain beliefs about the nature of depression were also found to predict differential response to cognitive therapy of depression. Limitations of the research and directions for further investigations of patient predictors of outcome in cognitive therapy of depression are provided.

Acute and one-year outcome of a randomised controlled trial of brief cognitive therapy for major depressive disorder in primary care

BACKGROUND

The consensus statement on the treatment of depression (Paykel & Priest, 1992) advocates the use of cognitive therapy techniques as an adjunct to medication.

METHOD

This paper describes a randomised controlled trial of brief cognitive therapy (BCT) plus 'treatment as usual' versus treatment as usual in the management of 48 patients with major depressive disorder presenting in primary care.

RESULTS

At the end of the acute phase, significantly more subjects (P < 0.05) met recovery criteria in the intervention group (n = 15) compared with the control group (n = 8). When initial neuroticism scores were controlled for, reductions in Beck Depression Inventory and Hamilton Rating Scale for Depression scores favoured the BCT group throughout the 12 months of follow-up.

CONCLUSIONS

BCT may be beneficial, but given the time constraints, therapists need to be more rather than less skilled in cognitive therapy. This, plus methodological limitations, leads us to advise caution before applying this approach more widely in primary care.

Cognitive therapy with inpatients

Psychotherapeutic interventions often play a major role in the treatment of patients who are hospitalized for depression. Much of the "therapeutic milieu" of the inpatient unit includes patient participation in group psychotherapy and in one-on-one psychotherapy with staff members. These interventions are designed not only to be primary treatments for depression, but are also used to enhance patients' compliance with pharmacotherapy. Cognitive therapy (CT) has been adapted for use with inpatients and has been used as an organizing theory for the hospital milieu in several inpatient units. Research on inpatient CT suggests that it is a beneficial treatment that enhances continuity of care after discharge from the hospital. This paper describes the general principles of inpatient CT, and discusses the various types of inpatient cognitive therapy units (CTUs) that have been developed. The benefits of such programs are described, and research regarding the effectiveness of inpatient CT is discussed.

The role of Axis II comorbidity in the management of patients with treatment-resistant depression

A significant proportion of antidepressant nonresponders have personality disorders. The relationship between antidepressant resistance and personality pathology is far from straightforward, however, and reflects a disproportionate "burden" of negative prognostic correlates, psychosocial risk factors, and problems that compromise effective therapeutic relationships. An important clinical ground rule is to avoid the reductionistic logical tautology that explains antidepressant failure as a consequence of personality disorder and, by implication, that the patient may deserve to suffer. In evaluating antidepressant-resistant patients, identification of pathologic personality traits or disorders may help provide important clues for future trials of both pharmacotherapy and psychotherapy, particularly in combination.

Cognitive therapy

The scientific approach advocated in CBT has increased its credibility with more biologically orientated therapists (who have remained sceptical of other psychodynamic models), making the approach acceptable to a broad group of psychiatrists. There is a rich clinical literature describing the techniques and applications of CBT in a wide variety of settings. The acquisition of a selection of the above texts offers a useful starting point, and scanning of major British and American psychiatry and psychology journals is likely to turn up at least one important paper every few months. Those with a commitment to research would benefit from subscribing to the journal Cognitive Therapy and Research. CBT does not aim to be a panacea for every disorder, and cognitive therapists are critical of its overzealous use by inadequately trained or poorly informed therapists. To practise effectively, the therapist needs a coherent cognitive model of the problem being treated and, as such, must explore the theoretical background literature and critically evaluate the data from process and outcome research. Hopefully, this 'scientist-practitioner' approach, tracing the emergence and development of the theory and principles of the model underpinning the therapy, means that cognitive therapists practise what they preach.