What is the best sequential treatment strategy in the treatment of depression? Adding pharmacotherapy to psychotherapy or vice versa?

Challenges and Opportunities in Interdisciplinary Research and Real-World Data for Treatment Sequences in Health Technology Assessments

With an ever-increasing number of treatment options, the assessment of treatment sequences has become crucial in health technology assessment (HTA). This review systematically explores the multifaceted challenges inherent in evaluating sequences, delving into their interplay and nuances that go beyond economic model structures. We synthesised a 'roadmap' of literature from key methodological studies, highlighting the evolution of recent advances and emerging research themes. These insights were compared against HTA guidelines to identify potential avenues for future research. Our findings reveal a spectrum of challenges in sequence evaluation, encompassing selecting appropriate decision-analytic modelling approaches and comparators, deriving appropriate clinical effectiveness evidence in the face of data scarcity, scrutinising effectiveness assumptions and statistical adjustments, considering treatment displacement, and optimising model computations. Integrating methodologies from diverse disciplines-statistics, epidemiology, causal inference, operational research and computer science-has demonstrated promise in addressing these challenges. An updated review of application studies is warranted to provide detailed insights into the extent and manner in which these methodologies have been implemented. Data scarcity on the effectiveness of treatment sequences emerged as a dominant concern, especially because treatment sequences are rarely compared in clinical trials. Real-world data (RWD) provide an alternative means for capturing evidence on effectiveness and future research should prioritise harnessing causal inference methods, particularly Target Trial Emulation, to evaluate treatment sequence effectiveness using RWD. This approach is also adaptable for analysing trials harbouring sequencing information and adjusting indirect comparisons when collating evidence from heterogeneous sources. Such investigative efforts could lend support to reviews of HTA recommendations and contribute to synthesising external control arms involving treatment sequences.

[Non-response to psychotherapy: concepts, problems and referral options]

AIM

In this paper we review the current literature on the clinical problem that some patients do not achieve response after adequately conducted psychotherapy. We explicate our understanding of nonresponse and treatment resistance including the operational definitions, summarize the theoretical explanations and empirical studies and put forward possible study designs and treatment options.

METHODS

Literature search using PubMed and Web of Science.

RESULTS

For the domain of psychotherapy, the term treatment resistance does not seem appropriate; instead, we use the more descriptive terms nonresponse and recurrent nonresponse. Generally, this topic is far less represented in psychotherapy than in pharmacotherapy. Controlled switching studies with a switch from pharmacotherapy to psychotherapy are rare and those switching from one psychotherapeutic approach to another are nearly nonexistent. Building on clinical considerations, we propose a flow-chart for clinical decision making after nonresponse in psychotherapy.

DISCUSSION

Learning from errors is highly beneficial. This principle should be more consistently followed up in psychotherapy research as well as in supervision and training. Guidelines should include consensual and evidence-based advice on how to deal with nonresponse and recurring nonresponse.

Two-Year Follow-Up after Treatment with the Cognitive Behavioral Analysis System of Psychotherapy versus Supportive Psychotherapy for Early-Onset Chronic Depression

BACKGROUND

Evidence on the long-term efficacy of psychotherapeutic approaches for chronic depression is scarce.

OBJECTIVE

To evaluate the effects of the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) compared to Supportive Psychotherapy (SP) 1 year and 2 years after treatment termination.

METHODS

In this study, we present 1- and 2-year follow-up assessments of a prospective, multicenter, evaluator-blinded, randomized clinical trial of outpatients with early-onset chronic major depression (n = 268). The initial treatment included 32 sessions of CBASP or SP over 48 weeks. The primary outcome was the rate of "well weeks" (Longitudinal Interval Follow-Up Evaluation; no/minimal symptoms) after 1 year and 2 years. The secondary outcomes were, among others, clinician- and self-rated depressive symptoms, response/remission rates, and quality of life.

RESULTS

Of the 268 randomized patients, 207 (77%) participated in the follow-up. In the intention-to-treat analysis, there was no statistically significant difference between CBASP and SP patients in experiencing well weeks (CBASP: mean [SD] of 48.6 [36.9] weeks; SP: 39.0 [34.8]; rate ratio 1.26, 95% CI 0.99-1.59, p = 0.057, d = 0.18) and in remission rates (CBASP: 1 year 40%, 2 years 40.2%; SP: 1 year 28.9%, 2 years 33%) in the 2 years after treatment. Statistically significant effects were found in favor of CBASP 1 year after treatment termination regarding the rate of well weeks, self-rated depressive symptoms, and depression-related quality of life.

CONCLUSIONS

CBASP lost its superiority over SP at some point between the first and the second year. This suggests the necessity of maintenance treatment for early-onset chronically depressed patients remitted with CBASP during the acute therapy phase, as well as the sequential integration of other treatment strategies, including medication for those who did not reach remission.

Benefits of Sequentially Adding Cognitive-Behavioral Therapy or Antidepressant Medication for Adults With Nonremitting Depression

OBJECTIVE

Adults with major depressive disorder frequently do not achieve remission with an initial treatment. Addition of psychotherapy for patients who do not achieve remission with antidepressant medication alone can target residual symptoms and protect against recurrence, but the utility of adding antidepressant medication after nonremission with cognitive-behavioral therapy (CBT) has received little study. The authors aimed to evaluate the acute and long-term outcomes resulting from both sequences of combination treatments.

METHODS

Previously untreated adults with major depression who were randomly assigned to receive escitalopram, duloxetine, or CBT monotherapy and completed 12 weeks of treatment without achieving remission entered an additional 12 weeks of combination treatment. For patients who did not achieve remission with CBT, escitalopram was added (CBT plus medication group) to their treatment, and for those who did not achieve remission with an antidepressant, CBT was added (medication plus CBT group) to their treatment. Patients who responded to the combination treatment entered an 18-month follow-up phase to assess risk of recurrence.

RESULTS

A total of 112 patients who did not achieve remission with a monotherapy entered combination treatment (41 who responded to monotherapy but did not achieve remission and 71 who did not respond to monotherapy). Overall, remission rates after subsequent combination therapy were significantly higher among patients who responded to monotherapy but did not achieve remission (61%) than among patients who did not respond to monotherapy (41%). Among patients who responded to monotherapy but did not achieve remission, the remission rate in the CBT plus medication group (89%) was higher than in the medication plus CBT group (53%). However, among patients whose depression did not respond to monotherapy, rates of response and remission were similar between the treatment arms. Higher levels of anxiety, both prior to monotherapy and prior to beginning combination treatment, predicted poorer outcomes for both treatment groups.

CONCLUSIONS

The order in which CBT and antidepressant medication were sequentially combined did not appear to affect outcomes. Addition of an antidepressant is an effective approach to treating residual symptoms for patients who do not achieve remission with CBT, as is adding CBT after antidepressant monotherapy. Patients who do not respond to one treatment modality warrant consideration for addition of the alternative modality.

Longitudinal Investigation of Psychotherapy Outcomes (LIPO): Description of the Study Protocol

Background: Despite extensive research in the field of psychotherapies, few studies have compared the primary psychotherapies of naturalistic design, which represents real-life situations. Objective: The objectives of this study were to evaluate three modalities of evidence-based psychotherapy for clinical, psychosocial, and biological outcomes and to identify the mediators and confounders of this process. Our primary hypothesis is that all psychotherapies will improve clinical and psychosocial outcomes and will increase BDNF levels. Methods: Design: longitudinal, naturalistic. Participants: One hundred twenty-six patients who underwent one of three evidence-based modalities of individual psychotherapy [psychodynamic psychotherapy (PDT), interpersonal psychotherapy (IPT), and cognitive-behavioral psychotherapy (CBT)] were included. Measure: Primary outcomes are divided into three domains of variables: clinical (general psychiatric symptoms), biological (serum BDNF levels), and psychosocial (resilience, quality of life, coping strategies, social support, and quality of life-adjusted years of life). Confounding/mediator variables included clinical (personality traits, type of psychotherapy, number of sessions, concomitant use of pharmacological treatment, history of previous psychotherapeutic treatment, medical and psychiatric comorbidities, and psychiatric diagnosis), psychosocial (psychosocial stressors, therapeutic alliance, and defense mechanism style), and other (religiosity) factors. Procedure: The follow-up period will be baseline and 6 months and 1 year after entering the study. The study will include 42 controls for biological variables only. Sample size calculation considered a significance level of 5% and a power of 80% to detect a difference of 0.22 with a standard deviation of 0.43, assuming losses of 20-30% of patients. The comparison between the modalities of psychotherapy will be by generalized estimating equations (GEE) model, the analysis of mediators by the Hayes method, and confounders by multivariate logistic regression. Discussion: The findings of this study are intended to demonstrate the outcomes of evidence-based psychotherapies for clinical, psychosocial, and biological parameters and to understand the mediators and confounders of this process in a real-life setting for patients with severe mental illness, thus contributing to the establishment of evidence-based public health policies in the field of psychological interventions.

Psychological therapies for treatment-resistant depression in adults

BACKGROUND

Antidepressants are a first-line treatment for adults with moderate to severe major depression. However, many people prescribed antidepressants for depression don't respond fully to such medication, and little evidence is available to inform the most appropriate 'next step' treatment for such patients, who may be referred to as having treatment-resistant depression (TRD). National Institute for Health and Care Excellence (NICE) guidance suggests that the 'next step' for those who do not respond to antidepressants may include a change in the dose or type of antidepressant medication, the addition of another medication, or the start of psychotherapy. Different types of psychotherapies may be used for TRD; evidence on these treatments is available but has not been collated to date.Along with the sister review of pharmacological therapies for TRD, this review summarises available evidence for the effectiveness of psychotherapies for adults (18 to 74 years) with TRD with the goal of establishing the best 'next step' for this group.

OBJECTIVES

To assess the effectiveness of psychotherapies for adults with TRD.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (until May 2016), along with CENTRAL, MEDLINE, Embase, and PsycINFO via OVID (until 16 May 2017). We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished and ongoing studies. There were no date or language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with participants aged 18 to 74 years diagnosed with unipolar depression that had not responded to minimum four weeks of antidepressant treatment at a recommended dose. We excluded studies of drug intolerance. Acceptable diagnoses of unipolar depression were based onthe Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) or earlier versions, International Classification of Diseases (ICD)-10, Feighner criteria, or Research Diagnostic Criteria. We included the following comparisons.1. Any psychological therapy versus antidepressant treatment alone, or another psychological therapy.2. Any psychological therapy given in addition to antidepressant medication versus antidepressant treatment alone, or a psychological therapy alone.Primary outcomes required were change in depressive symptoms and number of dropouts from study or treatment (as a measure of acceptability).

DATA COLLECTION AND ANALYSIS

We extracted data, assessed risk of bias in duplicate, and resolved disagreements through discussion or consultation with a third person. We conducted random-effects meta-analyses when appropriate. We summarised continuous outcomes using mean differences (MDs) or standardised mean differences (SMDs), and dichotomous outcomes using risk ratios (RRs).

MAIN RESULTS

We included six trials (n = 698; most participants were women approximately 40 years of age). All studies evaluated psychotherapy plus usual care (with antidepressants) versus usual care (with antidepressants). Three studies addressed the addition of cognitive-behavioural therapy (CBT) to usual care (n = 522), and one each evaluated intensive short-term dynamic psychotherapy (ISTDP) (n = 60), interpersonal therapy (IPT) (n = 34), or group dialectical behavioural therapy (DBT) (n = 19) as the intervention. Most studies were small (except one trial of CBT was large), and all studies were at high risk of detection bias for the main outcome of self-reported depressive symptoms.A random-effects meta-analysis of five trials (n = 575) showed that psychotherapy given in addition to usual care (vs usual care alone) produced improvement in self-reported depressive symptoms (MD -4.07 points, 95% confidence interval (CI) -7.07 to -1.07 on the Beck Depression Inventory (BDI) scale) over the short term (up to six months). Effects were similar when data from all six studies were combined for self-reported depressive symptoms (SMD -0.40, 95% CI -0.65 to -0.14; n = 635). The quality of this evidence was moderate. Similar moderate-quality evidence of benefit was seen on the Patient Health Questionnaire-9 Scale (PHQ-9) from two studies (MD -4.66, 95% CI 8.72 to -0.59; n = 482) and on the Hamilton Depression Rating Scale (HAMD) from four studies (MD -3.28, 95% CI -5.71 to -0.85; n = 193).High-quality evidence shows no differential dropout (a measure of acceptability) between intervention and comparator groups over the short term (RR 0.85, 95% CI 0.58 to 1.24; six studies; n = 698).Moderate-quality evidence for remission from six studies (RR 1.92, 95% CI 1.46 to 2.52; n = 635) and low-quality evidence for response from four studies (RR 1.80, 95% CI 1.2 to 2.7; n = 556) indicate that psychotherapy was beneficial as an adjunct to usual care over the short term.With the addition of CBT, low-quality evidence suggests lower depression scores on the BDI scale over the medium term (12 months) (RR -3.40, 95% CI -7.21 to 0.40; two studies; n = 475) and over the long term (46 months) (RR -1.90, 95% CI -3.22 to -0.58; one study; n = 248). Moderate-quality evidence for adjunctive CBT suggests no difference in acceptability (dropout) over the medium term (RR 0.98, 95% CI 0.66 to 1.47; two studies; n = 549) and lower dropout over long term (RR 0.80, 95% CI 0.66 to 0.97; one study; n = 248).Two studies reported serious adverse events (one suicide, two hospitalisations, and two exacerbations of depression) in 4.2% of the total sample, which occurred only in the usual care group (no events in the intervention group).An economic analysis (conducted as part of an included study) from the UK healthcare perspective (National Health Service (NHS)) revealed that adjunctive CBT was cost-effective over nearly four years.

AUTHORS' CONCLUSIONS

Moderate-quality evidence shows that psychotherapy added to usual care (with antidepressants) is beneficial for depressive symptoms and for response and remission rates over the short term for patients with TRD. Medium- and long-term effects seem similarly beneficial, although most evidence was derived from a single large trial. Psychotherapy added to usual care seems as acceptable as usual care alone.Further evidence is needed on the effectiveness of different types of psychotherapies for patients with TRD. No evidence currently shows whether switching to a psychotherapy is more beneficial for this patient group than continuing an antidepressant medication regimen. Addressing this evidence gap is an important goal for researchers.

Evidence-Based Applications of Combination Psychotherapy and Pharmacotherapy for Depression

Combination treatment with psychotherapy and antidepressant medication can be provided from the initiation of treatment, sequentially after nonremission with a single-modality treatment or sequentially after remission to buttress the patient's recovery to prevent recurrence. Combination treatment from the initiation of care is best reserved for patients with high depression severity. Sequential addition of treatments, particularly psychotherapy after nonremission to antidepressant medication, is the best supported method of combination, improving remission rates and reducing relapse and recurrence in the long term. However, uncertainty persists around the optimal form of psychotherapy to combine with antidepressant medication for maximizing long-term gains. Better outcomes from combination treatment have been strongest in clinical trials that limited pharmacotherapy to a single antidepressant; benefits of combination treatment have been substantially smaller in trials that allowed flexible use of multiple antidepressant classes. Patients with recurrent major depressive disorder who benefit from combination treatment have better long-term outcomes if an active treatment component is maintained during recovery.

Symptom course in inpatient and day clinic treatment of depression: Results from the INDDEP-Study

BACKGROUND

In major depression (MDD), hospital treatment is an option in more severe cases or if outpatient treatment failed. Psychosomatic hospitals in Germany provide treatment programs with multimodal psychotherapy, either in an inpatient or a day hospital setting. In the context of health care research, this study aimed (1) to compare characteristics of patients treated in psychosomatic day hospitals and inpatient units, (2) to compare the effectiveness of both treatment modalities.

METHODS

A naturalistic design was chosen to achieve external validity. 604 consecutive patients were assessed at admission, discharge and a 3-month follow-up. Primary outcome was defined as a reduction of depressive symptomatology (QIDS-C), secondary outcomes comprise overall functioning and quality of life. For a comparison of effectiveness, inpatient and day hospital samples were matched according to known predictors of outcome.

RESULTS

The few differences found between the inpatient and day hospital sample were related to severity of depression and physical impairment. Inpatients more often got antidepressant medication. Additionally, inpatients were treated significantly longer, due to a subgroup of patients with somatic co-morbidity. There were no differences when comparing effectiveness.

LIMITATIONS

When comparing treatment effectiveness, possible bias cannot be ruled out. There was no randomization or untreated control group.

CONCLUSIONS

In patients with a more severe depression and somatic co-morbidity, inpatient treatment might be preferred as compared to day hospital treatment. However, most patients can be treated in both settings.

The Three-Month Effect of Mobile Internet-Based Cognitive Therapy on the Course of Depressive Symptoms in Remitted Recurrently Depressed Patients: Results of a Randomized Controlled Trial

Background: Internet-based cognitive therapy with monitoring via text messages (mobile CT), in addition to treatment as usual (TAU), might offer a cost-effective way to treat recurrent depression. Method: Remitted patients with at least 2 previous episodes of depression were randomized to mobile CT in addition to TAU (n = 126) or TAU only (n = 113). A linear mixed model was used to examine the effect of the treatment condition on a 3-month course of depressive symptoms after remission. Both an intention-to-treat analysis (n = 239) and a completer analysis (n = 193) were used. Depressive symptoms were assessed using the Inventory of Depressive Symptomatology (IDS-SR₃₀) at baseline and 1.5 and 3 months after randomization. Results: Residual depressive symptoms showed a small but statistically significant decrease in the intention-to-treat group over 3 months in the mobile CT group relative to the TAU group (difference: -1.60 points on the IDS-SR₃₀ per month, 95% CI = -2.64 to -0.56, p = 0.003). The effect of the treatment condition on the depressive symptomatology at the 3-month follow-up was small to moderate (Cohen's d = 0.44). All analyses among completers (≥5 modules) showed more pronounced treatment effects. Adjustment for unequally distributed variables did not markedly affect the results. Conclusions: Residual depressive symptoms after remission showed a more favorable course over 3 months in the mobile CT group compared to the TAU group. These results are a first indication that mobile CT in addition to TAU is effective in treating recurrently depressed patients in remission. However, demonstration of its long-term effectiveness and replication remains necessary. © 2015 S. Karger AG, Basel.

Long-term effects of the treatment of depressive female inpatients in a naturalistic study: is early improvement a valid predictor of outcome?

Objectives. To examine the predictive value of early improvement for short- and long-term outcome in the treatment of depressive female inpatients and to explore the influence of comorbid disorders (CD). Methods. Archival data of a naturalistic sample of 277 female inpatients diagnosed with a depressive disorder was analyzed assessing the BDI at baseline, after 20 days and 30 days, posttreatment, and after 3 to 6 months at follow-up. Early improvement, defined as a decrease in the BDI score of at least 30% after 20 and after 30 days, and CD were analyzed using binary logistic regression. Results. Both early improvement definitions were predictive of remission at posttreatment. Early improvement after 30 days showed a sustained treatment effect in the follow-up phase, whereas early improvement after 20 days failed to show a persistent effect regarding remission at follow-up. CD were not significantly related neither at posttreatment nor at follow-up. At no time point CD moderated the prediction by early improvement. Conclusions. We show that early improvement is a valid predictor for short-term remission and at follow-up in an inpatient setting. CD did not predict outcome. Further studies are needed to identify patient subgroups amenable to more tailored treatments.