Short-term psychotherapy of depressive disorders: current status and future directions

Personalising psychotherapies for depression using a novel mixed methods approach: an example from Morita therapy

Background

Current quantitative methods for personalising psychotherapies for depression are unlikely to be able to inform clinical decision-making for hundreds of years. Novel alternative methods to generate hypotheses for prospective testing are therefore required, and we showcase mixed methods as one such approach. By exploring patients’ perspectives in depth, and integrating qualitative and quantitative data at the level of the individual, we may identify new potential psychosocial predictors of psychotherapy outcomes, potentially informing the personalisation of depression treatment in a shorter timeframe. Using Morita therapy (a Japanese psychotherapy) as an exemplar, we thus explored how Morita therapy recipients’ views on treatment acceptability explain their adherence and response to treatment.

Methods

The Morita trial incorporated a pilot randomised controlled trial of Morita therapy versus treatment as usual for depression, and post-treatment qualitative interviews. We recruited trial participants from general practice record searches in Devon, UK, and purposively sampled data from 16 participants for our mixed methods analysis. We developed typologies of participants’ views from our qualitative themes, and integrated these with quantitative data on number of sessions attended and whether participants responded to treatment in a joint typologies and statistics display. We enriched our analysis using participant vignettes to demonstrate each typology.

Results

We demonstrated that (1) participants who could identify with the principles of Morita therapy typically responded to treatment, regardless of how many sessions they attended, whilst those whose orientation towards treatment was incompatible with Morita therapy did not respond to treatment, again regardless of treatment adherence and (2) participants whose personal circumstances impeded their opportunity to engage in Morita therapy attended the fewest sessions, though still benefitted from treatment if the principles resonated with them.

Conclusions

We identified new potential relationships between “orientation” and outcomes, and “opportunity” and adherence, which could not have been identified using existing non-integrative methods. This mixed methods approach warrants replication in future trials and with other psychotherapies to generate hypotheses, based on typologies (or profiles) of patients for whom a treatment is more or less likely to be suitable, to be tested in prospective trials.

Trial registration

Current Controlled Trials, ISRCTN17544090. Registered on 23 July 2015.

Morita Therapy for depression (Morita Trial): an embedded qualitative study of acceptability

OBJECTIVE

To explore the views of UK-based recipients of Morita Therapy (MT) on the acceptability of MT.

DESIGN

Qualitative study nested within a pilot randomised controlled trial of MT (a Japanese psychological therapy largely unknown in the UK) versus treatment as usual, using post-treatment semistructured interviews analysed with a framework approach.

SETTING AND PARTICIPANTS

Participants who received MT as part of the Morita Trial, recruited for the trial from General Practice record searches in Devon, UK. Data from 16 participants were purposively sampled for analysis.

RESULTS

We identified five themes which, together, form a model of how different participants viewed and experienced MT. Overall, MT was perceived as acceptable by many participants who emphasised the value of the approach, often in comparison to other treatments they had tried. These participants highlighted how accepting and allowing difficulties as natural phenomena and shifting attention from symptoms to external factors had facilitated symptom reduction and a sense of empowerment. We found that how participants understood and related to the principles of MT, in light of their expectations of treatment, was significantly tied to the extent to which MT was perceived as acceptable. Our findings also highlighted the distinction between MT in principle and practice, with participants noting challenges of engaging with the process of therapy such as fear and discomfort around rest, needing sufficient support from the therapist and others, and the commitment of treatment.

CONCLUSIONS

People in the UK can accept the premise of MT, and consider the approach beneficial and novel. Therefore, proceeding to a large-scale trial of MT is appropriate with minor modifications to our clinical protocol. Participants' expectations and understandings of treatment play a key role in acceptability, and future research may investigate these potential moderators of acceptability in MT.

TRIAL REGISTRATION NUMBERC

ISRCTN17544090; Pre-results.

Morita Therapy for depression (Morita Trial): a pilot randomised controlled trial

OBJECTIVE

To address uncertainties prior to conducting a fully powered randomised controlled trial of Morita Therapy plus treatment as usual (TAU) versus TAU alone, or to determine that such a trial is not appropriate and/or feasible.

DESIGN

Pilot parallel group randomised controlled feasibility trial.

SETTING AND PARTICIPANTS

Participants aged ≥18 years with Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV major depressive disorder, with or without DSM-IV anxiety disorder(s), recruited from general practice record searches in Devon, UK.

INTERVENTIONS

We randomised participants on a 1:1 basis stratified by symptom severity, concealing allocation using a secure independent web-based system, to receive TAU (control) or 8-12 sessions of Morita Therapy, a Japanese psychological therapy, plus TAU (intervention).

OUTCOMES

Rates of recruitment, retention and treatment adherence; variance and estimated between-group differences in follow-up scores (on the Patient Health Questionnaire 9 (PHQ-9) (depressive symptoms); Generalised Anxiety Disorder Questionnaire 7 (anxiety symptoms); Short Form 36 Health Survey Questionnaire/Work and Social Adjustment Scale (quality of life); Morita Attitudinal Scale for Arugamama (attitudes)) and their correlation with baseline scores.

RESULTS

We recruited 68 participants, 5.1% (95% CI 3.4% to 6.6%) of those invited (34 control; 34 intervention); 64/68 (94%; 95% CI 88.3% to 99.7%) provided 4-month follow-up data. Participants had a mean age of 49 years and mean PHQ-9 score of 16.8; 61% were female. Twenty-four of 34 (70.6%) adhered to the minimum treatment dose. The follow-up PHQ-9 (future primary outcome measure) pooled SD was 6.4 (95% CI 5.5 to 7.8); the magnitude of correlation between baseline and follow-up PHQ-9 scores was 0.42 (95% CI 0.19 to 0.61). Of the participants, 66.7% and 30.0% recovered in the intervention and control groups, respectively; 66.7% and 13.3% responded to treatment in the intervention and control groups, respectively.

CONCLUSIONS

A large-scale trial of Morita Therapy would require 133 participants per group and is feasible with minor modifications to the pilot trial protocol. Morita Therapy shows promise in treating depression and may provide patients with a distinct alternative to current treatments.

TRIAL REGISTRATION NUMBER

ISRCTN17544090; Pre-results.

Treatment and Prevention of Depression

Depression is one of the most common and debilitating psychiatric disorders and is a leading cause of suicide. Most people who become depressed will have multiple episodes, and some depressions are chronic. Persons with bipolar disorder will also have manic or hypomanic episodes. Given the recurrent nature of the disorder, it is important not just to treat the acute episode, but also to protect against its return and the onset of subsequent episodes.

Several types of interventions have been shown to be efficacious in treating depression. The antidepressant medications are relatively safe and work for many patients, but there is no evidence that they reduce risk of recurrence once their use is terminated. The different medication classes are roughly comparable in efficacy, although some are easier to tolerate than are others. About half of all patients will respond to a given medication, and many of those who do not will respond to some other agent or to a combination of medications. Electro-convulsive therapy is particularly effective for the most severe and resistant depressions, but raises concerns about possible deleterious effects on memory and cognition. It is rarely used until a number of different medications have been tried.

Although it is still unclear whether traditional psychodynamic approaches are effective in treating depression, interpersonal psychotherapy (IPT) has fared well in controlled comparisons with medications and other types of psychotherapies. It also appears to have a delayed effect that improves the quality of social relationships and interpersonal skills. It has been shown to reduce acute distress and to prevent relapse and recurrence so long as it is continued or maintained. Treatment combining IPT with medication retains the quick results of pharmacotherapy and the greater interpersonal breadth of IPT, as well as boosting response in patients who are otherwise more difficult to treat. The main problem is that IPT has only recently entered clinical practice and is not widely available to those in need.

Cognitive behavior therapy (CBT) also appears to be efficacious in treating depression, and recent studies suggest that it can work for even severe depressions in the hands of experienced therapists. Not only can CBT relieve acute distress, but it also appears to reduce risk for the return of symptoms as long as it is continued or maintained. Moreover, it appears to have an enduring effect that reduces risk for relapse or recurrence long after treatment is over. Combined treatment with medication and CBT appears to be as efficacious as treatment with medication alone and to retain the enduring effects of CBT. There also are indications that the same strategies used to reduce risk in psychiatric patients following successful treatment can be used to prevent the initial onset of depression in persons at risk. More purely behavioral interventions have been studied less than the cognitive therapies, but have performed well in recent trials and exhibit many of the benefits of cognitive therapy.

Mood stabilizers like lithium or the anticonvulsants form the core treatment for bipolar disorder, but there is a growing recognition that the outcomes produced by modern pharmacology are not sufficient. Both IPT and CBT show promise as adjuncts to medication with such patients. The same is true for family-focused therapy, which is designed to reduce interpersonal conflict in the family. Clearly, more needs to be done with respect to treatment of the bipolar disorders.

Good medical management of depression can be hard to find, and the empirically supported psychotherapies are still not widely practiced. As a consequence, many patients do not have access to adequate treatment. Moreover, not everyone responds to the existing interventions, and not enough is known about what to do for people who are not helped by treatment. Although great strides have been made over the past few decades, much remains to be done with respect to the treatment of depression and the bipolar disorders.

A Case Study of Occupationally Focused Brief Dynamic Therapy Using Mann's Model of Central Conflict

For most people who work, social and occupational competence is inherent to a sense of well-being and support. When occupational competence is questioned by themselves or others, patients may present to clinicians with complaints of dysfunction in the work setting. For these patients, addressing work issues with immediacy and brevity may quickly resolve difficulties, preventing further escalation. Mann's model of time-limited brief psychodynamic therapy may prove to be a useful tool in addressing these issues. The author reviews the current literature regarding occupational dysfunction combined with literature supporting the usefulness of Mann's model of time-limited brief dynamic psychotherapy. A case is discussed demonstrating the integration of Mann's model into a current occupational theme, elucidating the central conflict as it pertains to the occupational setting.

Psychotherapy for depression: a randomized clinical trial comparing schema therapy and cognitive behavior therapy

BACKGROUND

The efficacy of Cognitive Behavior Therapy (CBT) for depression has been robustly supported, however, up to fifty percent of individuals do not respond fully. A growing body of research indicates Schema Therapy (ST) is an effective treatment for difficult and entrenched problems, and as such, may be an effective therapy for depression.

METHODS

In this randomized clinical trial the comparative efficacy of CBT and ST for depression was examined. 100 participants with major depression received weekly cognitive behavioral therapy or schema therapy sessions for 6 months, followed by monthly therapy sessions for 6 months. Key outcomes were comparisons over the weekly and monthly sessions of therapy along with remission and recovery rates. Additional analyses examined outcome for those with chronic depression and comorbid personality disorders.

RESULTS

ST was not significantly better (nor worse) than CBT for the treatment of depression. The therapies were of comparable efficacy on all key outcomes. There were no differential treatment effects for those with chronic depression or comorbid personality disorders.

LIMITATIONS

This study needs replication.

CONCLUSIONS

This preliminary research indicates that ST may provide an effective alternative therapy for depression.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders, part 1: update 2013 on the acute and continuation treatment of unipolar depressive disorders

OBJECTIVES

This 2013 update of the practice guidelines for the biological treatment of unipolar depressive disorders was developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal has been to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. The guidelines are intended for use by all physicians seeing and treating patients with these conditions.

METHODS

The 2013 update was conducted by a systematic update literature search and appraisal. All recommendations were approved by the Guidelines Task Force.

RESULTS

This first part of the guidelines (Part 1) covers disease definition, classification, epidemiology, and course of unipolar depressive disorders, as well as the management of the acute and continuation phase treatment. It is primarily concerned with the biological treatment (including antidepressants, other psychopharmacological medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of adults.

CONCLUSIONS

To date, there is a variety of evidence-based antidepressant treatment options available. Nevertheless there is still a substantial proportion of patients not achieving full remission. In addition, somatic and psychiatric comorbidities and other special circumstances need to be more thoroughly investigated. Therefore, further high-quality informative randomized controlled trials are urgently needed.

A randomized controlled trial of the efficacy and cost-effectiveness of a brief intensified cognitive behavioral therapy and/or pharmacotherapy for mood and anxiety disorders: design and methods

BACKGROUND

Anxiety and mood disorders involve a high disease burden and are associated with high economic costs. A stepped-care approach intervention and abbreviated diagnostic method are assumed to increase effectiveness and efficiency of the mental healthcare and are expected to reduce economic costs.

METHODS

Presented are the rationale, design, and methods of a two-armed randomized controlled trial comparing 'treatment as usual' (TAU) with a brief intensified cognitive behavioral therapy (CBT) and/or pharmacotherapy. Eligible participants (N=500) of five Dutch outpatient Mental Healthcare Centers are randomly assigned to either TAU or to the experimental condition (brief CBT and/or pharmacotherapy). Data on patients' progress and clinical effectiveness of treatment are assessed at baseline, post-treatment (3 months after baseline), and at 6 and 12 months post-treatment by Routine Outcome Monitoring (ROM). Cost analysis is performed on the obtained data.

DISCUSSION

Since few studies have investigated both the clinical and cost effectiveness of a stepped-care approach intervention and a shortened diagnostic ROM method in both anxiety and/or mood disorders within secondary mental health care, the results of this study might contribute to the improvement of (cost)-effective treatment options and diagnostic methods for these disorders.

A randomized controlled trial of cognitive-behavioral treatment for depression versus relaxation training for alcohol-dependent individuals with elevated depressive symptoms

OBJECTIVE

A previous pilot study found positive outcomes among alcohol-dependent individuals with elevated depressive symptoms who received cognitive-behavioral treatment for depression (CBT-D; n = 19) compared with a relaxation training control (RTC; n = 16). The current study represents a replication of this pilot study using a larger sample size and a longer follow-up assessment period.

METHOD

Patients entering a partial hospital drug and alcohol treatment program who met criteria for alcohol dependence and elevated depressive symptoms (Beck Depression Inventory score ≥ 15) were recruited and randomly assigned to receive eight individual sessions of CBT-D (n = 81) or RTC (n = 84).

RESULTS

There were significant improvements in depressive and alcohol use outcomes over time for all participants.Compared with RTC, the CBT-D condition had significantly lower levels of depressive symptoms, as measured by the Beck Depression Inventory, at the 6-week follow-up. However, this effect was inconsistent because there were no differences in the Modified Hamilton Rating Scale for Depression between conditions at that time point and there were no significant differences at any other follow-up. No significant between-group differences on alcohol use outcomes were found.

CONCLUSIONS

The current findings did not replicate the positive outcomes observed in the CBT-D condition in our previous pilot study. Possible explanations for why these findings were not replicated are discussed, as are theoretical and clinical implications of using CBT-D in alcohol treatment.

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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Clinical practice recommendations for depression

OBJECTIVE

To provide clinically relevant evidence-based recommendations for the management of depression in adults that are informative, easy to assimilate and facilitate clinical decision making.

METHOD

A comprehensive literature review of over 500 articles was undertaken using electronic database search engines (e.g. MEDLINE, PsychINFO and Cochrane reviews). In addition articles, book chapters and other literature known to the authors were reviewed. The findings were then formulated into a set of recommendations that were developed by a multidisciplinary team of clinicians who routinely deal with mood disorders. The recommendations then underwent consultative review by a broader advisory panel that included experts in the field, clinical staff and patient representatives.

RESULTS

The clinical practice recommendations for depression (Depression CPR) summarize evidence-based treatments and provide a synopsis of recommendations relating to each phase of the illness. They are designed for clinical use and have therefore been presented succinctly in an innovative and engaging manner that is clear and informative.

CONCLUSION

These up-to-date recommendations provide an evidence-based framework that incorporates clinical wisdom and consideration of individual factors in the management of depression. Further, the novel style and practical approach should promote uptake and implementation.

An adaptation of the Interpersonal Problem Areas Rating Scale: pilot and interrater agreement study

OBJECTIVE

This article describes the adaptation of a rating scale of interpersonal psychotherapy problem areas to include a fifth problem area appropriate to bipolar disorder and an interrater agreement study in identifying interpersonal problem areas and selecting a primary treatment focus if patients were to engage in treatment.

METHOD

Five research interpersonal psychotherapists assessed nine audiotapes of a single interview with five bipolar and four unipolar patients in which the interpersonal inventory and identification of problem areas were undertaken.

RESULTS

Raters agreed on presence and absence of problem areas in seven tapes. Kappas for identification of problem areas were 1.00 (grief), 0.77 (role dispute), 0.61 (role transition), 0.57 (interpersonal deficits) and 1.00 (loss of healthy self). Kappa for agreement on a primary clinical focus if patients were to engage in interpersonal psychotherapy treatment was 0.64.

CONCLUSIONS

The adaptation of the original scale to include an area pertinent to bipolar disorder proved to be applicable and relevant for use with this population. The results show substantial interrater agreement in identifying problem areas and potential treatment focus.

Brief interpersonal psychotherapy for depressed mothers whose children are receiving psychiatric treatment

OBJECTIVE

Depressed mothers of children with psychiatric illness struggle with both their own psychiatric disorder and the demands of caring for ill children. When maternal depression remains untreated, mothers suffer, and psychiatric illness in their offspring is less likely to improve. This randomized, controlled trial compared the interpersonal psychotherapy for depressed mothers (IPT-MOMS), a nine-session intervention based on standard interpersonal psychotherapy, to treatment as usual for depressed mothers with psychiatrically ill offspring.

METHOD

Forty-seven mothers meeting DSM-IV criteria for major depression were recruited from a pediatric mental health clinic where their school-age children were receiving psychiatric treatment and randomly assigned to IPT-MOMS (N=26) or treatment as usual (N=21). Mother-child pairs were assessed at three time points: baseline, 3-month follow-up, and 9-month follow-up. Child treatment was not determined by the study.

RESULTS

Compared to subjects assigned to treatment as usual, subjects assigned to IPT-MOMS showed significantly lower levels of depression symptoms, as measured by the Hamilton Depression Rating Scale, and higher levels of functioning, as measured by the Global Assessment of Functioning, at 3-month and 9-month follow-ups. Compared to the offspring of mothers receiving treatment as usual, the offspring of mothers assigned to IPT-MOMS showed significantly lower levels of depression as measured by the Children's Depressive Inventory at the 9-month follow-up.

CONCLUSIONS

Assignment to IPT-MOMS was associated with reduced levels of maternal symptoms and improved functioning at the 3- and 9-month follow-ups compared to treatment as usual. Maternal improvement preceded improvement in offspring, suggesting that maternal changes may mediate child outcomes.

Combined therapy of major depression with concomitant borderline personality disorder: comparison of interpersonal and cognitive psychotherapy

OBJECTIVE

The combination of antidepressants and brief psychotherapies has been proven more efficacious in treating major depression and is particularly recommended in patients with concomitant personality disorders. We compare the effects of 2 combined therapies, fluoxetine and interpersonal therapy (IPT) or fluoxetine and cognitive therapy (CT), on major depression in patients with borderline personality disorder (BPD).

METHOD

Thirty-five consecutive outpatients with a diagnosis of BPD and a major depressive episode (not bipolar and not psychotic) were enrolled. They were randomly assigned to 1 of the 2 combined treatments and treated for 24 weeks. Assessment included a semistructured interview, Clinical Global Impression (CGI) scale, Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HARS), Beck Depression Inventory-II (BDI-II), Social and Occupational Functioning Assessment Scale (SOFAS), Satisfaction Profile (SAT-P) for quality of life (QOL), and Inventory of Interpersonal Problems (IIP-64). Statistical analysis was performed using the univariate General Linear Model to calculate the effects of duration and type of treatment.

RESULTS

No significant differences between treatments were found at CGI, HDRS, BDI-II, and SOFAS score. Combined treatment with CT had greater effects on HARS score and on psychological functioning factor of SAT-P. Combined treatment with IPT was more effective on social functioning factor of SAT-P and on domains domineering or controlling and intrusive or needy of IIP-64.

CONCLUSIONS

Both combined therapies are efficacious in treating major depression in patients with BPD. Differences between CT and IPT concern specific features of subjective QOL and interpersonal problems. These findings lack reliable comparisons and need to be replicated.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders in Primary Care

These practical guidelines for the biological treatment of unipolar depressive disorders in primary care settings were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). They embody the results of a systematic review of all available clinical and scientific evidence pertaining to the treatment of unipolar depressive disorders and offer practical recommendations for general practitioners encountering patients with these conditions. The guidelines cover disease definition, classification, epidemiology and course of unipolar depressive disorders, and the principles of management in the acute, continuation and maintenance phase. They deal primarily with biological treatment (including antidepressants, other psychopharmacological and hormonal medications, electroconvulsive therapy, light therapy).

Randomised controlled trial of interpersonal psychotherapy and cognitive-behavioural therapy for depression

BACKGROUND

Interpersonal psychotherapy and cognitive-behavioural therapy (CBT) are established as effective treatments for major depression. Controversy remains regarding their effectiveness for severe and melancholic depression.

AIMS

To compare the efficacy of interpersonal psychotherapy and CBT in people receiving out-patient treatment for depression and to explore response in severe depression (Montgomery-Asberg Depression Rating Scale (MADRS) score above 30), and in melancholic depression.

METHOD

Randomised clinical trial of 177 patients with a principal Axis I diagnosis of major depressive disorder receiving 16 weeks of therapy comprising 8-19 sessions. Primary outcome was improvement in MADRS score from baseline to end of treatment.

RESULTS

There was no difference between the two psychotherapies in the sample as a whole, but CBT was more effective than interpersonal psychotherapy in severe depression, and the response was comparable with that for mild and moder-ate depression. Melancholia did not predict poor response to either psychotherapy.

CONCLUSIONS

Both therapies are equally effective for depression but CBT may be preferred in severe depression.

Depression diagnosis and antidepressant treatment among depressed VA primary care patients

This study examined the extent to which 3559 VA primary care patients with depression symptomatology received depression diagnoses and/or antidepressant prescriptions. Symptomatology was classified as mild (13%), moderate (42%) or severe (45%) based on SCL-20 scores. Diagnosis and treatment was related to depression severity and other patient characteristics. Overall, 44% were neither diagnosed nor treated. Only 22% of those neither diagnosed nor treated for depression received treatment for other psychopathology. Depression treatment performance measures dependent on diagnoses and antidepressant prescriptions from administrative databases exclude undiagnosed patients with significant, treatable, symptomatology.

Depression and cigarette smoking independently relate to reduced health-related quality of life among Canadians living with hepatitis C

BACKGROUND

Many people living with chronic viral hepatitis C (HCV) report reduced health-related quality of life. The relative contribution of behavioural, psychosocial and HCV disease factors to reduction in HCV health-related quality of life is not well understood. The objectives of the present study were to compare standardized health-related quality of life scores between Canadian HCV patients and age-matched Canadian and American norms, and to examine the relative contribution of biopsychosocial variables (ie, cigarette smoking, alcohol intake and depression) to health-related quality of life scores among Canadian HCV patients.

METHODS

HCV RNA-positive patients were recruited during their first visit to the Ottawa Hospital Viral Hepatitis Clinic (Ottawa, Ontario). A questionnaire assessing health behaviours, health-related quality of life and depressed mood was completed. Data on liver studies, liver biopsy findings and HIV serostatus were also collected.

RESULTS

A total of 123 participants (71% men) ranging from 20 to 67 years of age were evaluated. All had compensated liver function. Patients reported significantly lower health-related quality of life compared with age-matched Canadian and American normative samples. In a series of hierarchical multiple regression models, depression and smoking were independently related to compromised health-related quality of life scores, even after controlling for sociodemographic variables and health behaviours.

DISCUSSION

These results highlight the value of adopting a biopsychosocial model of HCV care. Depressed mood and smoking behaviour should be evaluated in HCV patients. Empirically validated psychological and pharmacological treatments for depression and smoking cessation may improve health-related quality of life in HCV infected patients.

Combined treatment of major depression in patients with borderline personality disorder: a comparison with pharmacotherapy

OBJECTIVE

Combined treatment with psychotherapy and antidepressants is more effective than monotherapies. Recent data show that combined therapy has better results in patients with depression and Axis II codiagnosis. The aim of this study was to compare combined treatment using interpersonal psychotherapy (IPT) with pharmacotherapy alone in patients with depression and borderline personality disorder (BPD).

METHODS

There were 39 consecutive outpatients diagnosed with BPD who presented with a major depressive episode enrolled in this study. They were randomly assigned to 1 of 2 treatment groups: fluoxetine 20 mg to 40 mg daily or fluoxetine 20 mg to 40 mg daily plus IPT 1 session weekly. Owing to noncompliance, 7 patients dropped out. We assessed the 32 patients who completed the 24 weeks of treatment at baseline, Week 12, and Week 24, using a semistructured interview for clinical characteristics, the Clinical Global Impression Scale (CGI), the Hamilton Depression Rating Scale (HDRS), and the Hamilton Anxiety Rating Scale (HARS), and 2 self-report questionnaires, that is, the Satisfaction Profile (SAT-P) for quality of life and the 64-item Inventory for Interpersonal Problems (IIP-64). We performed statistical analysis, using univariate general linear models with 2 factors: duration and type of treatment.

RESULTS

Changes in remission rates, CGI, and HARS score did not differ between treatments. According to changes in the HDRS scores; changes in psychological functioning and social functioning scores on the SAT-P; and changes in vindictive or self-centred, cold or distant, intrusive or needy, and socially inhibited scores on the IIP-64, combined therapy was superior to fluoxetine alone.

CONCLUSIONS

Combined therapy with IPT is more effective than antidepressant therapy alone, both in treating symptoms of major depression and in improving dimensions of quality of life and interpersonal functioning.

Cost-utility of brief psychological treatment for depression and anxiety

BACKGROUND

The cost-utility of brief therapy compared with cognitive-behavioural therapy (CBT) and care as usual in the treatment of depression and anxiety has not yet been determined.

AIMS

To assess the cost-utility of brief therapy compared with CBT and care as usual.

METHOD

A pragmatic randomised controlled trial involving 702 patients was conducted at 7 Dutch mental healthcare centres (MHCs). Patients were interviewed at baseline and then every 3 months over a period of 1.5 years, during which time data were collected on direct costs, indirect costs and quality of life.

RESULTS

The mean direct costs of treatment at the MHCs were significantly lower for brief therapy than for CBT and care as usual. However, after factoring in other healthcare costs and indirect costs, no significant differences between the treatment groups could be detected. We found no significant differences in quality-adjusted life-years between the groups.

CONCLUSIONS

Cost-utility did not differ significantly between the three treatment groups.

Design and rationale for a randomized, controlled trial of interpersonal psychotherapy and citalopram for depression in coronary artery disease (CREATE)

OBJECTIVE

Recognition that depression is associated with increased morbidity and mortality in coronary artery disease (CAD) patients has augmented the need for evidence-based treatment guidelines. This article presents the design of a multisite, Canadian trial of the efficacy, safety, and tolerability of interpersonal psychotherapy (IPT), an empirically supported, depression-focused therapy, and the selective serotonin reuptake inhibitor citalopram, alone or in combination, in the treatment of major depression in CAD patients.

METHODS

Two hundred eighty stable CAD patients with a current major depressive episode of at least 4 weeks' duration, based on the Structured Clinical Interview for Depression (SCID), and who have a baseline score >19 on a centralized, telephone-administered, 24-item Hamilton Depression Rating Scale (HAM-D) will be randomly assigned to receive 12 weekly IPT sessions or 12 weekly sessions of standardized clinical management (CM). Patients are also randomly assigned to receive 20 to 40 mg per day of citalopram or pill-placebo. This results in a 2-by-2 factorial design with four groups: IPT plus pill-placebo, IPT plus citalopram, CM plus pill-placebo, and CM plus citalopram. This permits the evaluation of both IPT and citalopram. Blinded, centralized, 24-item, HAM-D telephone ratings constitute the primary outcome variable. The self-report Beck Depression Inventory-II is the secondary outcome. Analyses will involve the intent-to-treat principle with last observation carried forward for incomplete assessments.

RESULTS

Not applicable.

CONCLUSIONS

The results of this trial will contribute to the development of evidence-based clinical guidelines for managing depression in the context of CAD.

A systematic review of research findings on the efficacy of interpersonal therapy for depressive disorders

OBJECTIVE

Interpersonal psychotherapy (IPT) is a time-limited psychotherapy for major depression. The aim of this study is to summarize findings from controlled trials of the efficacy of IPT in the treatment of depressive spectrum disorders (DSD) using a meta-analytic approach.

METHODS

Studies of randomized clinical trials of IPT efficacy were located by searching all available data bases from 1974 to 2002. The searches employed the following MeSH categories: Depression/ Depressive Disorder; Interpersonal therapy; Outcome/Adverse Effects/Efficacy; in the identified studies. The efficacy outcomes were: remission; clinical improvement; the difference in depressive symptoms between the two arms of the trial at endpoint, and no recurrence. Drop out rates were used as an index of treatment acceptability.

RESULTS

Thirteen studies fulfilled inclusion criteria and four meta-analyses were performed. IPT was superior in efficacy to placebo in nine studies (Weight Mean Difference (WMD) - 3.57 [-5.9, -1.16]). The combination of IPT and medication did not show an adjunctive effect compared to medication alone for acute treatment (RR 0.78 [0.30, 2.04]), for maintenance treatment (RR 1.01 [0.81, 1.25]), or for prophylactic treatment (RR 0.70 [0.30, 1.65]). IPT was significantly better than CBT (WMD -2.16 [-4.16,-0.15]).

CONCLUSION

The efficacy of IPT proved to be superior to placebo, similar to medication and did not increase when combined with medication. Overall, IPT was more efficacious than CBT. Current evidence indicates that IPT is an efficacious psychotherapy for DSD and may be superior to some other manualized psychotherapies.

Cognition in mania and depression: psychological models and clinical implications

Affective disorders, including bipolar disorder and major depressive disorder, are highly prevalent throughout the world and are extremely disabling. Diagnostic and Statistical Manual criteria and psychological models strongly implicate cognitive dysfunctions as being integral to our understanding of these disorders. We review the findings from studies that have used neurocognitive tests and functional imaging techniques to explore abnormal cognition in affective disorders. In particular, we highlight the evidence for cognitive dysfunctions that persist into full clinical remission, and the recent trend toward the use of "hot" processing tasks, involving emotionally charged stimuli, as a means of differentiating between the cognitive underpinnings of mania and depression. The clinical relevance of these developments is discussed.

Sequenced treatment alternatives to relieve depression (STAR*D): rationale and design

STAR*D is a multisite, prospective, randomized, multistep clinical trial of outpatients with nonpsychotic major depressive disorder. The study compares various treatment options for those who do not attain a satisfactory response with citalopram, a selective serotonin reuptake inhibitor antidepressant. The study enrolls 4000 adults (ages 18-75) from both primary and specialty care practices who have not had either a prior inadequate response or clear-cut intolerance to a robust trial of protocol treatments during the current major depressive episode. After receiving citalopram (level 1), participants without sufficient symptomatic benefit are eligible for randomization to level 2 treatments, which entail four switch options (sertraline, bupropion, venlafaxine, cognitive therapy) and three citalopram augment options (bupropion, buspirone, cognitive therapy). Those who receive cognitive therapy (switch or augment options) at level 2 without sufficient improvement are eligible for randomization to one of two level 2A switch options (venlafaxine or bupropion). Level 2 and 2A participants are eligible for random assignment to two switch options (mirtazapine or nortriptyline) and to two augment options (lithium or thyroid hormone) added to the primary antidepressant (citalopram, bupropion, sertraline, or venlafaxine) (level 3). Those without sufficient improvement at level 3 are eligible for level 4 random assignment to one of two switch options (tranylcypromine or the combination of mirtazapine and venlafaxine). The primary outcome is the clinician-rated, 17-item Hamilton Rating Scale for Depression, administered at entry and exit from each treatment level through telephone interviews by assessors masked to treatment assignments. Secondary outcomes include self-reported depressive symptoms, physical and mental function, side-effect burden, client satisfaction, and health care utilization and cost. Participants with an adequate symptomatic response may enter the 12-month naturalistic follow-up phase with brief monthly and more complete quarterly assessments.

[Interpersonal Therapy: a brief and focal model]

Psychotherapy is a particular form of treatment in Psychiatry. Its use is widespread and has many different approaches.

OBJECTIVE

In this article, the author makes some considerations about Interpersonal Therapy (IPT), a brief and focal psychotherapy. Initially created to treat depression, other researchers had successfully increase its spectrum. It could be divided in three phases. Initial, when the therapist makes the diagnosis of the disorder and also the interpersonal problematic is pointed out; the patient received a sick role. Intermediary when the focus is treated, and the final phase when the therapist encourages the patient to recognize and consolidate gains and prepare the patient to use it in the future.

METHODS

It is stressed that IPT is a testable form of psychotherapy and the scientific evidences of its efficacy are showed.

CONCLUSIONS

The results assure that IPT is an efficient form of psychotherapy for depression with a great acceptability from the patients.

Improvement in social-interpersonal functioning after cognitive therapy for recurrent depression

BACKGROUND

Cognitive therapy reduces depressive symptoms of major depressive disorder, but little is known about concomitant reduction in social-interpersonal dysfunction.

METHOD

We evaluated social-interpersonal functioning (self-reported social adjustment, interpersonal problems and dyadic adjustment) and depressive symptoms (two self-report and two clinician scales) in adult outpatients (n=156) with recurrent major depressive disorder at several points during a 20-session course of acute phase cognitive therapy. Consenting acute phase responders (n=84) entered a 2-year follow-up phase, which included an 8-month experimental trial comparing continuation phase cognitive therapy to assessment-only control.

RESULTS

Social-interpersonal functioning improved after acute phase cognitive therapy (dyadic adjustment d=0.47; interpersonal problems d=0.91; social adjustment d=1.19), but less so than depressive symptoms (d=1.55). Improvement in depressive symptoms and social-interpersonal functioning were moderately to highly correlated (r=0.39-0.72). Improvement in depressive symptoms was partly independent of social-interpersonal functioning (r=0.55-0.81), but improvement in social-interpersonal functioning independent of change in depressive symptoms was not significant (r=0.01-0.06). In acute phase responders, continuation phase therapy did not further enhance social-interpersonal functioning, but improvements in social-interpersonal functioning were maintained through the follow-up.

CONCLUSIONS

Social-interpersonal functioning is improved after acute phase cognitive therapy and maintained in responders over 2 years. Improvement in social-interpersonal functioning is largely accounted for by decreases in depressive symptoms.

Background and rationale for the sequenced treatment alternatives to relieve depression (STAR*D) study

Sequenced Treatment Alternatives to Relieve Depression (STAR*D) attempts to fill in major clinical information gaps and to evaluate the theoretical principles and clinical beliefs that currently guide pharmacotherapy of major depressive disorder. The study is conducted in representative participant groups and settings using clinical management tools that easily can be applied in daily practice. Outcomes include clinical outcomes and health care utilization and cost estimates. Research findings should be immediately applicable to, and easily implemented in, the daily primary and specialty care practices. This article provides the overall rationale for STAR*D and details the rationale for key design, measurement, and analytic features of the study.

Diagnosis and definition of treatment-resistant depression

Treatment-resistant depression (TRD) typically refers to inadequate response to at least one antidepressant trial of adequate doses and duration. TRD is a relatively common occurrence in clinical practice, with up to 50% to 60% of the patients not achieving adequate response following antidepressant treatment. A diagnostic re-evaluation is essential to the proper management of these patients. In particular, the potential role of several contributing factors, such as medical and psychiatric comorbidity, needs to be taken into account. An accurate and systematic assessment of TRD is a challenge to both clinicians and researchers, with the use of clinician-rated or self-rated instruments being perhaps quite helpful. It is apparent that there may be varying degrees of treatment resistance. Some staging methods to assess levels of treatment resistance in depression are being developed, but need to be tested empirically.

Separate personality traits from states to predict depression

Results have been inconsistent regarding the ability of personality measures to predict future depression severity levels, leading some researchers to question the validity of personality assessment, especially when patients are acutely depressed. Using a combination of regression and factor analytic techniques, we separated the variance of personality measures into stable trait and variable state-affect components. Findings supported the hypotheses that depression severity measured at different time points would correlate with both stable trait and concurrent state-affect components in personality measures, whereas change in depression severity would correlate with state changes but not with stable trait scores. Thus, personality assessments tap both state affect and trait variance, with the state-affect variance masking the trait variance when patients are depressed.

Interpersonal problems, personality pathology, and social adjustment after cognitive therapy for depression

The authors examined the level and structure of the Inventory of Interpersonal Problems-Circumplex version (IIP-C; L. M. Horowitz, L. E. Alden, J. S. Wiggins, & A. L. Pincus, 2000) before and after 20 sessions of acute-phase cognitive therapy for depression (N = 118), as well as associations with the Schedule for Nonadaptive and Adaptive Personality (L. A. Clark, 1993b) and the Social Adjustment Scale--Self-Report version (M. M. Weissman & S. Bothwell, 1976). Interpersonal problems had a 3-factor structure (Interpersonal Distress, Love, and Dominance), with the latter 2 factors approximating a circumplex, both before and after therapy. Interpersonal Distress decreased and social adjustment increased with therapy, but the Love and Dominance dimensions were relatively stable, similar to personality constructs. Social adjustment related negatively to Interpersonal Distress but not to Love or Dominance. Personality pathology related broadly to Interpersonal Distress and discriminantly to Love and Dominance. These findings support the reliability and validity of the IIP-C and are discussed in the context of personality theory and measurement.

Skating to where the puck is going to be: a plan for clinical trials and translation research in mood disorders

As part of the National Institute of Mental Health Strategic Plan for Mood Disorders Research effort, the Clinical Trials and Translation Workgroup was asked to define priorities for clinical trials in mood disorders and for research on how best to translate the results of such research to clinical practice settings. Through two face-to-face meetings and a series of conference calls, we established priorities based on the literature to date and what was known about research currently in progress in this area. We defined five areas of priority that cut across developmental stages, while noting that research on adult mood disorders was at a more advanced stage in each of these areas than research on child or geriatric disorders. The five areas of priority are: 1) maximizing the effectiveness and cost-effectiveness of initial (acute) treatments for mood disorders already known to be efficacious in selected populations and settings when they are applied across all populations and care settings; 2) learning what further treatments or services are most likely to reduce symptoms and improve functioning when the first treatment is delivered well, but the mood disorder does not remit or show adequate improvement; 3) learning what treatments or services are most cost-effective in preventing recurrence or relapse and maintaining optimal functioning after a patient's mood disorder has remitted or responded maximally to treatment; 4) developing and validating clinical, psychosocial, biological, or other markers that predict: a) which treatments are most effective, b) course of illness, c) risk of adverse events/tolerability and acceptability for individual patients or well-defined subgroups of patients; 5) developing clinical trial designs and methods that result in lower research costs and greater generalizability earlier in the treatment development and testing process. A rationale for the importance of each of these priorities is provided.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 1: Acute and continuation treatment of major depressive disorder

These practice guidelines for the biological treatment of unipolar depressive disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal for developing these guidelines was to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating patients with these conditions. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for depressive disorders, as well as from meta-analyses and reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into four levels of evidence (A-D). This first part of the guidelines covers disease definition, classification, epidemiology and course of unipolar depressive disorders, as well as the management of the acute and continuation-phase treatment. These guidelines are primarily concerned with the biological treatment (including antidepressants, other psychopharmacological and hormonal medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of young adults and also, albeit to a lesser extent, children, adolescents and older adults.

Awareness, diagnosis, and treatment of depression

OBJECTIVES

To review recent findings on the epidemiology, burden, diagnosis, comorbidity, and treatment of depression, particularly in general medical settings; to delineate barriers to the recognition, diagnosis, and optimal management of depression in general medical settings; and to summarize efforts under way to reduce some of these barriers.

DESIGN

MEDLINE searches were conducted to identify scientific articles published during the previous 10 years addressing depression in general medical settings and epidemiology, co-occurring conditions, diagnosis, costs, outcomes, and treatment. Articles relevant to the objective were selected and summarized.

CONCLUSIONS

Depression occurs commonly, causing suffering, functional impairment, increased risk of suicide, added health care costs, and productivity losses. Effective treatments are available both when depression occurs alone and when it co-occurs with general medical illnesses. Many cases of depression seen in general medical settings are suitable for treatment within those settings. About half of all cases of depression in primary care settings are recognized, although subsequent treatments often fall short of existing practice guidelines. When treatments of documented efficacy are used, short-term patient outcomes are generally good. Barriers to diagnosing and treating depression include stigma; patient somatization and denial; physician knowledge and skill deficits; limited time; lack of availability of providers and treatments; limitations of third-party coverage; and restrictions on specialist, drug, and psychotherapeutic care. Public and professional education efforts, destigmatization, and improvement in access to mental health care are all needed to reduce these barriers.

Is psychotherapy an effective treatment for melancholia and other severe depressive states?

The treatment of severe depression with psychotherapy, alone, is controversial. In this paper, we review the historical, conceptual, and empirical contexts of this controversy. In addition to work by others, we review recent work from our institute which has examined the psychobiological substrates of response to treatment in depressive subtypes. We examine the traditional categories that describe severe depressions. The features and psychobiological correlates of melancholia are discussed, as is the relationship between melancholia and aging. Research on treatment of melancholia and other severe depressive states with psychotherapies such as cognitive behavior therapy (CBT) and interpersonal psychotherapy (IPT) is reviewed in detail. We conclude that although some melancholic patients are responsive to IPT or CBT, there is not yet compelling evidence that melancholic patients respond to psychotherapy as well as they do to medications. The potentially mediating effects of hypercortisolism, alterations of sleep neurophysiology, and disturbances of information processing and regional cerebral metabolism represent fertile grounds for future investigation. We discuss the practical implications of the literature reviewed.

Treatment of atypical depression with cognitive therapy or phenelzine: a double-blind, placebo-controlled trial

BACKGROUND

Patients with atypical depression are more likely to respond to monoamine oxidase inhibitors than to tricyclic antidepressants. They are frequently offered psychotherapy in the absence of controlled tests. There are no prospective, randomized, controlled trials, to our knowledge, of psychotherapy for atypical depression or of cognitive therapy compared with a monoamine oxidase inhibitor. Since there is only 1 placebo-controlled trial of cognitive therapy, this trial fills a gap in the literature on psychotherapy for depression.

METHODS

Outpatients with DSM-III-R major depressive disorder and atypical features (N = 108) were treated in a 10-week, double-blind, randomized, controlled trial comparing acute-phase cognitive therapy or clinical management plus either phenelzine sulfate or placebo. Atypical features were defined as reactive mood plus at least 2 additional symptoms: hypersomnia, hyperphagia, leaden paralysis, or lifetime sensitivity to rejection.

RESULTS

With the use of an intention-to-treat strategy, the response rates (21-item Hamilton Rating Scale for Depression score, < or =9) were significantly greater after cognitive therapy (58%) and phenelzine (58%) than after pill placebo (28%). Phenelzine and cognitive therapy also reduced symptoms significantly more than placebo according to contrasts after a repeated-measures analysis of covariance and random regression with the use of the blind evaluator's final Hamilton Rating Scale for Depression score. The scores between cognitive therapy and phenelzine did not differ significantly. Supplemental analyses of other symptom severity measures confirm the finding.

CONCLUSIONS

Cognitive therapy may offer an effective alternative to standard acute-phase treatment with a monoamine oxidase inhibitor for outpatients with major depressive disorder and atypical features.

Emotional distress before coronary bypass grafting limits the benefits of surgery

BACKGROUND

The inclusion of large, heterogeneous groups of patients for coronary bypass grafting (CABG) surgery has resulted in a more mixed treatment outcome. Thus it becomes important to identify patients who are less likely to benefit from surgery or who may require additional support to improve treatment outcome. The aim of the present study was to examine whether psychological status measured before CABG can contribute to prediction of short- and long-term outcomes of the surgery.

METHODS AND RESULTS

One hundred seventy-one consecutive patients from two large university hospitals in Stockholm completed a psychosocial questionnaire before being scheduled for surgery. One year after CABG, patients again completed the questionnaire. Follow-up of medical charts was conducted during the first 3 years after surgery. All major cardiac events (cardiac death, definite myocardial infarction, revascularization, and unstable angina verified by angiography or myocardial scintigraphy) were recorded. Although the overall effect of surgery was excellent in the majority of cases, the patients exhibiting a high degree of distress (anxiety, depression, and tiredness) before surgery assessed their status as being much worse both before the operation and at the 1-year follow-up. Equally important was the fact that patients considered distressed before surgery had significantly higher rates of cardiac events (16%) in the 3-year follow-up period compared with nondistressed patients (5%) (chi-square=5.11, degrees of freedom=1, p < 0.02).

CONCLUSIONS

Systematic evaluation and treatment of emotional distress in the candidates for coronary revascularization may be expected to result in more optimal subjective results and a reduction in the number of serious cardiac events after surgery.

Cognitive-behavioral treatment for depression in alcoholism

Alcoholics with depressive symptoms score > or = 10 on the Beck Depression Inventory (A.T. Beck, C. H. Ward, M. Mendelson, J. Mock, & J. Erbaugh, 1961) received 8 individual sessions of cognitive-behavioral treatment for depression (CBT-D, n = 19) or a relaxation training control (RTC; n = 16) plus standard alcohol treatment. CBT-D patients had greater reductions in somatic depressive symptoms and depressed and anxious mood than RTC patients during treatment. Patients receiving CBT-D had a greater percentage of days abstinent but not greater overall abstinence or fewer drinks per day during the first 3-month follow-up. However, between the 3- and 6-month follow-ups, CBT-D patients had significantly better alcohol use outcomes on total abstinence (47% vs. 13%), percent days abstinent (90.5% vs. 68.3%), and drinks per day (0.46 vs. 5.71). Theoretical and clinical implications of using CBT-D in alcohol treatment are discussed.

A prospective test of criteria for response, remission, relapse, recovery, and recurrence in depressed patients treated with cognitive behavior therapy

The definitions that are commonly employed to describe the outcome of the depressive disorders are often used in inconsistent ways and remain largely untested. The lack of a standard and valid set of outcome definitions hinders the study of the naturalistic course and treatment of depressive disorders. In the present study, we operationalized definitions for response, remission, relapse, recovery, and recurrence and examined their validity in a sample of depressed patients treated with cognitive behavior therapy. Validity was evaluated by the ability of the definitions to predict subsequent outcome in acute treatment and during a 3 year follow-up period. All five definitions demonstrated moderate to excellent validity. Moreover, we were able to empirically distinguish response from remission, and relapse from recurrence, despite the frequent confusion of these terms in the literature. Several of the findings suggest that continued refinement of the outcome definitions may enhance validity even further.