Efficacy of trial-based cognitive therapy, behavioral activation and treatment as usual in the treatment of major depressive disorder: preliminary findings from a randomized clinical trial

Individual behavioral activation in the treatment of depression: A meta analysis

OBJECTIVE

Behavioral activation (BA) is an extensively examined treatment for depression which is relatively simple to apply in comparison to other psychotherapies. BA aims to increase positive interactions between a person and the environment. All previous meta-analyses focused on BA in groups and guided self-help, but none focused on BA in individual psychotherapy. The goal of the current meta-analysis is to examine the pooled effects of trials comparing individual BA to control conditions.

METHODS

We conducted systematic searches and conducted random effects meta-analyses to examine the effects of BA.

RESULTS

We included 22 randomized controlled trials (with 819 patients) comparing individual behavioral activation with waitlist, usual care, or other control conditions on distal treatment outcomes. Nine studies were rated as low risk of bias. We found a large effect (Hedges' g = 0.85; 95% CI: 0.57; 1.1) with high heterogeneity (75%; 95% CI: 62; 83). When only studies with low risk of bias were considered, the effect size was still significant (g = 0.56; 95% CI: 0.09; 1.03), with high heterogeneity (I² = 80%; 95% CI: 66; 89; prediction interval: -0.85; 1.98).

CONCLUSION

BA is an effective, relatively simple type of therapy that can be applied broadly in differing populations/.

Optimized short-forms of the Cognitive Distortions Questionnaire

INTRODUCTION

The Cognitive Distortions Questionnaire (CD-Quest) is a self-report questionnaire that assesses common cognitive distortions. Although the CD-Quest has excellent psychometric properties, its length may limit its use.

METHODS

We attempted to develop short-forms of the CD-Quest using RiskSLIM - a machine learning method to build short-form scales that can be scored by hand. Each short-form was fit to maximize concordance with the total CD-Quest score for a specified number of items based on an objective function, in this case R², by selecting an optimal subset of items and an optimal set of small integer weights. The models were trained in a sample of US undergraduate students (N = 906). We then validated each short-form on five independent samples: two samples of undergraduate students in Brazil (Ns = 182, 183); patients with depression in Brazil (N = 62); patients with social anxiety disorder in the US (N = 198); and psychiatric outpatients in Turkey (N = 269).

RESULTS

A 9-item short-form with integer scoring was created that reproduced the total 15-item CD-Quest score in all validation samples with excellent accuracy (R² = 90.4-93.6%). A 5-item ultra-short-form had good accuracy (R² = 78.2-85.5%).

DISCUSSION

A 9-item short-form and a 5-item ultra-short-form of the CD-Quest both reproduced full CD-Quest scores with excellent to good accuracy. These shorter versions of the full CD-Quest could facilitate measurement of cognitive distortions for users with limited time and resources.

A Randomized Clinical Trial to Assess the Efficacy of Online-Treatment with Trial-Based Cognitive Therapy, Mindfulness-Based Health Promotion and Positive Psychotherapy for Post-Traumatic Stress Disorder during the COVID-19 Pandemic: A Study Protocol

BACKGROUND

Research suggests the use of different forms of therapy as a way of decreasing dropout rates in the treatment of post-traumatic stress disorder (PTSD). The psychotherapies to be assessed in this study are trial-based cognitive therapy (TBCT), mindfulness-based health promotion (MBHP) and positive psychotherapy (PPT).

OBJECTIVES

(1) to assess the online efficacy of TBCT compared to MBHP and PPT to reduce the symptoms of PTSD in the context of the Coronavirus Disease 2019 (COVID-19) pandemic; (2) to compare the efficacy of these psychotherapies in improving anxiety, depression, guilt and in promoting well-being; and (3) to describe how professionals perceive online treatment.

METHODS

A randomized, multicenter, single-blind clinical trial will be conducted, with three separate arms. An estimated sample of 135 patients will receive either TBCT, MBHP or PPT and will be treated through online, individual, weekly visits, totaling 14 sessions. The primary outcome will be CAPS-5 and secondary outcomes will be HADS and WHO-5. The variables used to mediate these outcomes will be the Trauma-Related Guilt Inventory (TRGI), Negative Core Beliefs Inventory (NCBI) and the California Psychotherapy Alliance Scale (CALPAS-P).

EXPECTED RESULTS

PTSD symptoms are expected to be reduced after TBCT, MBHP and PPT. No statistical difference is expected to be found among the three.

DISCUSSION

The present study will evaluate and contribute towards the development of new psychotherapeutic options for patients with PTSD. The results of this study will allow the dissemination of new effective and adaptable interventions for patients with PTSD.

Behavioural activation and trial-based cognitive therapy may be beneficial to reduce suicidal ideation in major depressive disorder: A post hoc study from a clinical trial

WHAT IS KNOWN AND OBJECTIVE

The suicidality spectrum is a clinical challenge because of the difficulty of its management and its association with mortality. Few studies have investigated psychotherapies for reducing the components of suicidality. In this study, we compared the effect of behavioural activation (BA), trial-based cognitive therapy (TBCT) - both added to antidepressant (AD) treatment - and treatment as usual (TAU) in mitigating suicidal ideation in patients with major depressive disorder (MDD).

METHODS

A post hoc study was conducted with data from a randomized clinical trial. Secondary analyses compared the treatments using scores from the items that evaluated suicidal ideation with the HAM-D (HAM-D-3) and BDI (BDI-9). A composite measurement was constructed by summing the scores from the two items (HAM-D-3 plus BDI-9).

RESULTS AND DISCUSSION

Seventy-six patients were analysed (BA + AD = 24; TBCT + AD = 26 and TAU = 26). In HAM-D-3, the BA + AD group showed a statistically greater reduction than the TAU group. In BDI-9, the three groups did not show significant differences. In the HAM-D-3 plus BDI-9, TBCT + AD reduced ideations more than the TAU group. There were no differences among the psychotherapies in any of the measures. Sensitivity analyses showed improvement in suicidal ideation in both psychotherapies compared to TAU.

WHAT IS NEW AND CONCLUSION

This is one of the few studies that evaluated the effect of BA and TBCT in lowering suicidal ideation. Adding these therapies to ADs seems to decrease suicidal ideation. We suggest the possible beneficial effects of BA and TBCT in the management of suicidal ideation in patients with recurrent MDD. Our findings need further studies to confirm these results.

Quality of life in patients with comorbid serious mental illness and chronic diseases: A structural equation model

AIMS

To investigate the factors affecting the quality of life among adults with comorbid serious mental illness and chronic diseases.

DESIGN

Descriptive, cross-sectional study design.

METHODS

In total, 204 patients with serious mental illness were recruited from two hospitals. Self-reported data were collected using the Brief Psychiatric Rating Scale, Internalised Stigma of Mental Illness, Patient Activation Measure and brief version of the World Health Organization Quality of Life Instrument. Data were collected between July 2018 - January 2019. The structural equation model was applied to examine the associations among the study variables.

RESULTS

Internalized stigma (β = -0.479, p = .002) had the greatest direct effect on quality of life, followed by patient activation (β = 0.238, p = .002), severity of comorbidities (β = -0.207, p = .002) and psychiatric symptoms (β = -0.186, p = .006). In addition, psychiatric symptoms directly influenced the severity of comorbidities, which in turn directly influenced internalized stigma and then in turn directly influenced patient activation and ultimately influenced quality of life.

CONCLUSION

The relationship between internalized stigma and quality of life is significantly mediated by patient activation. This finding provides a theoretical basis for developing patient activation interventions for patients with comorbid mental and chronic diseases, which potentially improve the quality of life of this population.

IMPACT

Multiple comorbidities cause impaired quality of life in patients with serious mental illnesses. We found that patient activation plays an important role in the management of chronic diseases for achieving more favourable quality of life, but this is negatively affected by internalized stigma. These findings can help mental health professionals develop tailored intervention strategies to enhance quality of life by promoting patient activation and reducing internalized stigma, psychiatric symptoms, and comorbidity severity in patients with comorbid serious mental illnesses and chronic diseases.

Behavioural activation therapy for depression in adults

BACKGROUND

Behavioural activation is a brief psychotherapeutic approach that seeks to change the way a person interacts with their environment. Behavioural activation is increasingly receiving attention as a potentially cost-effective intervention for depression, which may require less resources and may be easier to deliver and implement than other types of psychotherapy.

OBJECTIVES

To examine the effects of behavioural activation compared with other psychological therapies for depression in adults. To examine the effects of behavioural activation compared with medication for depression in adults. To examine the effects of behavioural activation compared with treatment as usual/waiting list/placebo no treatment for depression in adults.

SEARCH METHODS

We searched CCMD-CTR (all available years), CENTRAL (current issue), Ovid MEDLINE (1946 onwards), Ovid EMBASE (1980 onwards), and Ovid PsycINFO (1806 onwards) on the 17 January 2020 to identify randomised controlled trials (RCTs) of 'behavioural activation', or the main elements of behavioural activation for depression in participants with clinically diagnosed depression or subthreshold depression. We did not apply any restrictions on date, language or publication status to the searches. We searched international trials registries via the World Health Organization's trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished or ongoing trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of behavioural activation for the treatment of depression or symptoms of depression in adults aged 18 or over. We excluded RCTs conducted in inpatient settings and with trial participants selected because of a physical comorbidity. Studies were included regardless of reported outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles/abstracts and full-text manuscripts for inclusion. Data extraction and 'Risk of bias' assessments were also performed by two review authors in duplicate. Where necessary, we contacted study authors for more information.

MAIN RESULTS

Fifty-three studies with 5495 participants were included; 51 parallel group RCTs and two cluster-RCTs. We found moderate-certainty evidence that behavioural activation had greater short-term efficacy than treatment as usual (risk ratio (RR) 1.40, 95% confidence interval (CI) 1.10 to 1.78; 7 RCTs, 1533 participants), although this difference was no longer evident in sensitivity analyses using a worst-case or intention-to-treat scenario. Compared with waiting list, behavioural activation may be more effective, but there were fewer data in this comparison and evidence was of low certainty (RR 2.14, 95% CI 0.90 to 5.09; 1 RCT, 26 participants). No evidence on treatment efficacy was available for behavioural activation versus placebo and behavioural activation versus no treatment. We found moderate-certainty evidence suggesting no evidence of a difference in short-term treatment efficacy between behavioural activation and CBT (RR 0.99, 95% CI 0.92 to 1.07; 5 RCTs, 601 participants). Fewer data were available for other comparators. No evidence of a difference in short term-efficacy was found between behavioural activation and third-wave CBT (RR 1.10, 95% CI 0.91 to 1.33; 2 RCTs, 98 participants; low certainty), and psychodynamic therapy (RR 1.21, 95% CI 0.74 to 1.99; 1 RCT,60 participants; very low certainty). Behavioural activation was more effective than humanistic therapy (RR 1.84, 95% CI 1.15 to 2.95; 2 RCTs, 46 participants; low certainty) and medication (RR 1.77, 95% CI 1.14 to 2.76; 1 RCT; 141 participants; moderate certainty), but both of these results were based on a small number of trials and participants. No evidence on treatment efficacy was available for comparisons between behavioural activation versus interpersonal, cognitive analytic, and integrative therapies. There was moderate-certainty evidence that behavioural activation might have lower treatment acceptability (based on dropout rate) than treatment as usual in the short term, although the data did not confirm a difference and results lacked precision (RR 1.64, 95% CI 0.81 to 3.31; 14 RCTs, 2518 participants). Moderate-certainty evidence did not suggest any difference in short-term acceptability between behavioural activation and waiting list (RR 1.17, 95% CI 0.70 to 1.93; 8 RCTs. 359 participants), no treatment (RR 0.97, 95% CI 0.45 to 2.09; 3 RCTs, 187 participants), medication (RR 0.52, 95% CI 0.23 to 1.16; 2 RCTs, 243 participants), or placebo (RR 0.72, 95% CI 0.31 to 1.67; 1 RCT; 96 participants; low-certainty evidence). No evidence on treatment acceptability was available comparing behavioural activation versus psychodynamic therapy. Low-certainty evidence did not show a difference in short-term treatment acceptability (dropout rate) between behavioural activation and CBT (RR 1.03, 95% CI 0.85 to 1.25; 12 RCTs, 1195 participants), third-wave CBT (RR 0.84, 95% CI 0.33 to 2.10; 3 RCTs, 147 participants); humanistic therapy (RR 1.06, 95% CI 0.20 to 5.55; 2 RCTs, 96 participants) (very low certainty), and interpersonal, cognitive analytic, and integrative therapy (RR 0.84, 95% CI 0.32 to 2.20; 4 RCTs, 123 participants). Results from medium- and long-term primary outcomes, secondary outcomes, subgroup analyses, and sensitivity analyses are summarised in the text.

AUTHORS' CONCLUSIONS

This systematic review suggests that behavioural activation may be more effective than humanistic therapy, medication, and treatment as usual, and that it may be no less effective than CBT, psychodynamic therapy, or being placed on a waiting list. However, our confidence in these findings is limited due to concerns about the certainty of the evidence. We found no evidence of a difference in short-term treatment acceptability (based on dropouts) between behavioural activation and most comparison groups (CBT, humanistic therapy, waiting list, placebo, medication, no treatment or treatment as usual). Again, our confidence in all these findings is limited due to concerns about the certainty of the evidence. No data were available about the efficacy of behaioural activation compared with placebo, or about treatment acceptability comparing behavioural activation and psychodynamic therapy, interpersonal, cognitive analytic and integrative therapies. The evidence could be strengthened by better reporting and better quality RCTs of behavioural activation and by assessing working mechanisms of behavioural activation.