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Tröger A, Miguel C, Ciharova M, de Ponti N, Durman G, Cuijpers P, Karyotaki E. Baseline depression severity as moderator on depression outcomes in psychotherapy and pharmacotherapy. J Affect Disord 2024; 344:86-99. [PMID: 37820960 DOI: 10.1016/j.jad.2023.10.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 10/02/2023] [Accepted: 10/08/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Evidence-based treatments for adult depression include psychotherapy and pharmacotherapy, yet little is known about how baseline depression severity moderates treatment outcome. OBJECTIVES We aimed to compare the effects of psychotherapy and pharmacotherapy for adult depression and to examine the association between baseline depression severity and treatment outcome, converting multiple baseline depression measures into the scores of the Beck Depression Inventory, second edition (BDI-II). METHODS We conducted systematic searches in bibliographical databases up to September 2022 to identify randomized controlled trials (RCTs) in which psychotherapy was compared with pharmacotherapy in the treatment of adult depression. Various meta-regressions using the baseline depression severity as predictor of the relative effects of psychotherapy and pharmacotherapy were performed. RESULTS We identified 65 RCTs including 7250 participants for the meta-analyses and 56 RCTs including 5548 participants for the meta-regression. We found no significant difference between psychotherapy and pharmacotherapy (g = -0.08, 95 % CI: -0.2 to 0.04, p = 0.193) and baseline depression severity was not significantly associated with the relative effects of psychotherapy and pharmacotherapy (B = 0.0032, SE = 0.0096, p = 0.74). Results were similar in several sensitivity analyses. LIMITATIONS Limitations included the low quality of the included studies, and the omission of long-term effects and within-study variability. CONCLUSIONS We found no indication for a moderation effect of baseline depression severity on the relative effects of psychotherapy and pharmacotherapy. Thus, other factors such as availability and patients' preference must be considered when deciding for treatment options.
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Affiliation(s)
- Anna Tröger
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universitat Dresden, Dresden, Germany.
| | - Clara Miguel
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Marketa Ciharova
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Nino de Ponti
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Güldehan Durman
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Eirini Karyotaki
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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Psychological interventions to prevent relapse in anxiety and depression: A systematic review and meta-analysis. PLoS One 2022; 17:e0272200. [PMID: 35960783 PMCID: PMC9374222 DOI: 10.1371/journal.pone.0272200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 07/14/2022] [Indexed: 11/19/2022] Open
Abstract
Objectives
The aim of this review is to establish the effectiveness of psychological relapse prevention interventions, as stand-alone interventions and in combination with maintenance antidepressant treatment (M-ADM) or antidepressant medication (ADM) discontinuation for patients with remitted anxiety disorders or major depressive disorders (MDD).
Methods
A systematic review and a meta-analysis were conducted. A literature search was conducted in PubMed, PsycINFO and Embase for randomised controlled trials (RCTs) comparing psychological relapse prevention interventions to treatment as usual (TAU), with the proportion of relapse/recurrence and/or time to relapse/recurrence as outcome measure.
Results
Thirty-six RCTs were included. During a 24-month period, psychological interventions significantly reduced risk of relapse/recurrence for patients with remitted MDD (RR 0.76, 95% CI: 0.68–0.86, p<0.001). This effect persisted with longer follow-up periods, although these results were less robust. Also, psychological interventions combined with M-ADM significantly reduced relapse during a 24-month period (RR 0.76, 95% CI: 0.62–0.94, p = 0.010), but this effect was not significant for longer follow-up periods. No meta-analysis could be performed on relapse prevention in anxiety disorders, as only two studies focused on relapse prevention in anxiety disorders.
Conclusions
In patients with remitted MDD, psychological relapse prevention interventions substantially reduce risk of relapse/recurrence. It is recommended to offer these interventions to remitted MDD patients. Studies on anxiety disorders are needed.
Systematic review registration number
PROSPERO 2018: CRD42018103142.
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Kappelmann N, Rein M, Fietz J, Mayberg HS, Craighead WE, Dunlop BW, Nemeroff CB, Keller M, Klein DN, Arnow BA, Husain N, Jarrett RB, Vittengl JR, Menchetti M, Parker G, Barber JP, Bastos AG, Dekker J, Peen J, Keck ME, Kopf-Beck J. Psychotherapy or medication for depression? Using individual symptom meta-analyses to derive a Symptom-Oriented Therapy (SOrT) metric for a personalised psychiatry. BMC Med 2020; 18:170. [PMID: 32498707 PMCID: PMC7273646 DOI: 10.1186/s12916-020-01623-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 05/07/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Antidepressant medication (ADM) and psychotherapy are effective treatments for major depressive disorder (MDD). It is unclear, however, if treatments differ in their effectiveness at the symptom level and whether symptom information can be utilised to inform treatment allocation. The present study synthesises comparative effectiveness information from randomised controlled trials (RCTs) of ADM versus psychotherapy for MDD at the symptom level and develops and tests the Symptom-Oriented Therapy (SOrT) metric for precision treatment allocation. METHODS First, we conducted systematic review and meta-analyses of RCTs comparing ADM and psychotherapy at the individual symptom level. We searched PubMed Medline, PsycINFO, and the Cochrane Central Register of Controlled Trials databases, a database specific for psychotherapy RCTs, and looked for unpublished RCTs. Random-effects meta-analyses were applied on sum-scores and for individual symptoms for the Hamilton Rating Scale for Depression (HAM-D) and Beck Depression Inventory (BDI) measures. Second, we computed the SOrT metric, which combines meta-analytic effect sizes with patients' symptom profiles. The SOrT metric was evaluated using data from the Munich Antidepressant Response Signature (MARS) study (n = 407) and the Emory Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) study (n = 234). RESULTS The systematic review identified 38 RCTs for qualitative inclusion, 27 and 19 for quantitative inclusion at the sum-score level, and 9 and 4 for quantitative inclusion on individual symptom level for the HAM-D and BDI, respectively. Neither meta-analytic strategy revealed significant differences in the effectiveness of ADM and psychotherapy across the two depression measures. The SOrT metric did not show meaningful associations with other clinical variables in the MARS sample, and there was no indication of utility of the metric for better treatment allocation from PReDICT data. CONCLUSIONS This registered report showed no differences of ADM and psychotherapy for the treatment of MDD at sum-score and symptom levels. Symptom-based metrics such as the proposed SOrT metric do not inform allocation to these treatments, but predictive value of symptom information requires further testing for other treatment comparisons.
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Affiliation(s)
- Nils Kappelmann
- Max Planck Institute of Psychiatry, Kraepelinstraße 2-10, 80804, Munich, Germany.
- International Max Planck Research School for Translational Psychiatry (IMPRS-TP), Munich, Germany.
| | - Martin Rein
- Max Planck Institute of Psychiatry, Kraepelinstraße 2-10, 80804, Munich, Germany
| | - Julia Fietz
- Max Planck Institute of Psychiatry, Kraepelinstraße 2-10, 80804, Munich, Germany
- International Max Planck Research School for Translational Psychiatry (IMPRS-TP), Munich, Germany
| | - Helen S Mayberg
- Department of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - W Edward Craighead
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
- Department of Psychology, Emory University, Atlanta, GA, USA
| | - Boadie W Dunlop
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Charles B Nemeroff
- Institute for Early Life Adversity Research, University of Texas Dell Medical School in Austin, Austin, TX, USA
| | - Martin Keller
- Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, RI, USA
| | - Daniel N Klein
- Department of Psychology, Stony Brook University, Stony Brook, NY, USA
| | - Bruce A Arnow
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, 94304, USA
| | - Nusrat Husain
- Division of Psychology and Mental Health, The University of Manchester, Manchester, UK
| | - Robin B Jarrett
- Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Marco Menchetti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Gordon Parker
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
| | - Jacques P Barber
- Gordon F. Derner School of Psychology, Adelphi University, Garden City, New York, USA
| | - Andre G Bastos
- Contemporary Institute of Psychoanalysis and Transdisciplinarity of Porto Alegre, Porto Alegre, Brazil
| | - Jack Dekker
- Department of Research, Arkin Mental Health Care, Amsterdam, Netherlands
| | - Jaap Peen
- Department of Research, Arkin Mental Health Care, Amsterdam, Netherlands
| | - Martin E Keck
- Max Planck Institute of Psychiatry, Kraepelinstraße 2-10, 80804, Munich, Germany
| | - Johannes Kopf-Beck
- Max Planck Institute of Psychiatry, Kraepelinstraße 2-10, 80804, Munich, Germany
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Cuijpers P, Noma H, Karyotaki E, Vinkers CH, Cipriani A, Furukawa TA. A network meta-analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression. World Psychiatry 2020; 19:92-107. [PMID: 31922679 PMCID: PMC6953550 DOI: 10.1002/wps.20701] [Citation(s) in RCA: 199] [Impact Index Per Article: 49.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
No network meta-analysis has examined the relative effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression, while this is a very important clinical issue. We conducted systematic searches in bibliographical databases to identify randomized trials in which a psychotherapy and a pharmacotherapy for the acute or long-term treatment of depression were compared with each other, or in which the combination of a psychotherapy and a pharmacotherapy was compared with either one alone. The main outcome was treatment response (50% improvement between baseline and endpoint). Remission and acceptability (defined as study drop-out for any reason) were also examined. Possible moderators that were assessed included chronic and treatment-resistant depression and baseline severity of depression. Data were pooled as relative risk (RR) using a random-effects model. A total of 101 studies with 11,910 patients were included. Depression in most studies was moderate to severe. In the network meta-analysis, combined treatment was more effective than psychotherapy alone (RR=1.27; 95% CI: 1.14-1.39) and pharmacotherapy alone (RR=1.25; 95% CI: 1.14-1.37) in achieving response at the end of treatment. No significant difference was found between psychotherapy alone and pharmacotherapy alone (RR=0.99; 95% CI: 0.92-1.08). Similar results were found for remission. Combined treatment (RR=1.23; 95% CI: 1.05-1.45) and psychotherapy alone (RR=1.17; 95% CI: 1.02-1.32) were more acceptable than pharmacotherapy. Results were similar for chronic and treatment-resistant depression. The combination of psychotherapy and pharmacotherapy seems to be the best choice for patients with moderate depression. More research is needed on long-term effects of treatments (including cost-effectiveness), on the impact of specific pharmacological and non-pharmacological approaches, and on the effects in specific populations of patients.
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Affiliation(s)
- Pim Cuijpers
- Department of Clinical, Neuro and Developmental PsychologyAmsterdam Public Health Research Institute, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Hisashi Noma
- Department of Data ScienceInstitute of Statistical MathematicsTokyoJapan
| | - Eirini Karyotaki
- Department of Clinical, Neuro and Developmental PsychologyAmsterdam Public Health Research Institute, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Christiaan H. Vinkers
- Department of PsychiatryAmsterdam UMC (location VUmc)AmsterdamThe Netherlands,Department of Anatomy and NeurosciencesAmsterdam UMC (location VUmc)AmsterdamThe Netherlands
| | - Andrea Cipriani
- Department of Psychiatry Warneford Hospital, University of OxfordOxfordUK,Oxford Health NHS Foundation Trust, Warneford HospitalOxfordUK
| | - Toshi A. Furukawa
- Department of Health Promotion and Human BehaviorKyoto University Graduate School of Medicine, School of Public HealthKyotoJapan
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Yan G, Zhang M, Liu Y, Yin M. Efficacy of vortioxetine combined cognitive behaviour intervention therapy on brain-derived neurotrophic factor level on depressive patients. Psychogeriatrics 2019; 19:475-481. [PMID: 30780196 DOI: 10.1111/psyg.12426] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/29/2018] [Accepted: 01/06/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND To evaluate the effect of vortioxetine combined with cognitive behaviour intervention on the level of brain-derived neurotrophic factor (BDNF) in the serum of patients with depression and its therapeutic effect. METHODS A total of 82 depressive patients treated at the School of Basic Medicine, Heilongjiang University of Chinese Medicine from January 2017 to June 2017 were randomised into a control group (n = 41) and intervention group (n = 41) according to a random number table. Both groups were given vortioxetine treatment, while the intervention group adopted an additional cognitive-behavioural therapy at the same time. The therapeutic effect was evaluated using the Hamilton Depression Scale (HAMD). The cognitive function was evaluated using continuous performance test (CPT) and Wisconsin card sorting test (WCST). The changes of BDNF level were detected with the use of enzyme-linked immunosorbent assay. RESULTS The HAMD score of the intervention group was obviously lower than that of the control group after treatment (P < 0.001). WCST test showed that the number of trials, perseverative errors and non-perseverative errors in the intervention group were significantly lower than those in the control group, while the correct matching number and the number of categories achieved were significantly higher than those in the control group (all P < 0.001). Results of CPT showed that the correct number of responses to stimulus, the verbal fluency and the fluency of classification in the intervention group were significantly higher than those in the control group (all P < 0.05). Moreover, after treatment, the serum BDNF level of the intervention group was significantly higher than that in the control group (P < 0.001). CONCLUSIONS Vortioxetine combined with cognitive behavioural therapy has a good clinical effect and can largely improve the cognitive function of depressive patients.
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Affiliation(s)
- Guanyun Yan
- School of Humanities and Social Sciences, Harbin Medical University, Harbin, China
| | - Meng Zhang
- School of Humanities and Social Sciences, Harbin Medical University, Harbin, China
| | - Yafang Liu
- School of Basic Medicine, Heilongjiang University of Chinese Medicine, Harbin, China
| | - Mei Yin
- School of Humanities and Social Sciences, Harbin Medical University, Harbin, China
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Huang F, Tang YL, Zhao M, Wang Y, Pan M, Wang Y, Qian Q. Cognitive-Behavioral Therapy for Adult ADHD: A Randomized Clinical Trial in China. J Atten Disord 2019; 23:1035-1046. [PMID: 28866911 DOI: 10.1177/1087054717725874] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Cognitive-behavioral therapy (CBT) is effective for adult ADHD, and booster sessions may improve long-term outcome. This study was designed to investigate the effects of group CBT and its booster sessions for Chinese adult patients with ADHD. METHOD There were CBT only group ( n = 43), CBT +booster group ( n = 43), and control group with patients on the waiting list ( n = 22). The primary outcome was the score of the ADHD-Rating Scale (ADHD-RS). Secondary outcomes included emotion, executive function (EF), impulsivity, self-esteem, and life quality at 12th and 24th week. RESULTS At 12th week, the score of ADHD-RS, EF, and impulsivity showed significant improvement in CBT +booster group comparing with control group. At 24th week, differences between CBT only group and CBT +booster group were not significant. CONCLUSION CBT was effective for Chinese adult patients with ADHD. Booster sessions do not appear to provide additional benefits.
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Affiliation(s)
- Fang Huang
- 1 Peking University Sixth Hospital/Institute of Mental Health, National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China.,2 Key Laboratory of Mental Health, Ministry of Health(Peking University), Beijing, China
| | - Yi-Lang Tang
- 3 Emory University, School of Medicine, Atlanta, GA, USA.,4 Atlanta VA Medical Center, Decatur, GA, USA
| | - Mengjie Zhao
- 1 Peking University Sixth Hospital/Institute of Mental Health, National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China.,2 Key Laboratory of Mental Health, Ministry of Health(Peking University), Beijing, China
| | - Yanfei Wang
- 1 Peking University Sixth Hospital/Institute of Mental Health, National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China.,2 Key Laboratory of Mental Health, Ministry of Health(Peking University), Beijing, China
| | - Meirong Pan
- 1 Peking University Sixth Hospital/Institute of Mental Health, National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China.,2 Key Laboratory of Mental Health, Ministry of Health(Peking University), Beijing, China
| | - Yufeng Wang
- 1 Peking University Sixth Hospital/Institute of Mental Health, National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China.,2 Key Laboratory of Mental Health, Ministry of Health(Peking University), Beijing, China
| | - Qiujin Qian
- 1 Peking University Sixth Hospital/Institute of Mental Health, National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China.,2 Key Laboratory of Mental Health, Ministry of Health(Peking University), Beijing, China
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Ijaz S, Davies P, Williams CJ, Kessler D, Lewis G, Wiles N. Psychological therapies for treatment-resistant depression in adults. Cochrane Database Syst Rev 2018; 5:CD010558. [PMID: 29761488 PMCID: PMC6494651 DOI: 10.1002/14651858.cd010558.pub2] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Sharea Ijaz
- Population Health Sciences, Bristol Medical School, University of BristolNIHR CLAHRC West at University Hospitals Bristol NHS Foundation TrustLewins Mead, Whitefriars BuildingBristolUKBS1 2NT
| | - Philippa Davies
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge HallBristolUKBS8 2PS
| | - Catherine J Williams
- University of BristolSchool of Social and Community Medicine39 Whatley RoadBristolUKBS8 2PS
| | - David Kessler
- University of BristolSchool of Social and Community Medicine39 Whatley RoadBristolUKBS8 2PS
| | - Glyn Lewis
- UCLUCL Division of Psychiatry67‐73 Riding House StLondonUKW1W 7EJ
| | - Nicola Wiles
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge HallBristolUKBS8 2PS
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Differing antidepressant maintenance methodologies. Contemp Clin Trials 2017; 61:87-95. [DOI: 10.1016/j.cct.2017.07.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 07/17/2017] [Accepted: 07/20/2017] [Indexed: 12/28/2022]
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Vittengl JR, Clark LA, Thase ME, Jarrett RB. Initial Steps to inform selection of continuation cognitive therapy or fluoxetine for higher risk responders to cognitive therapy for recurrent major depressive disorder. Psychiatry Res 2017; 253:174-181. [PMID: 28388454 PMCID: PMC5481171 DOI: 10.1016/j.psychres.2017.03.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 03/20/2017] [Accepted: 03/20/2017] [Indexed: 10/19/2022]
Abstract
Responders to acute-phase cognitive therapy (A-CT) for major depressive disorder (MDD) often relapse or recur, but continuation-phase cognitive therapy (C-CT) or fluoxetine reduces risks for some patients. We tested composite moderators of C-CT versus fluoxetine's preventive effects to inform continuation treatment selection. Responders to A-CT for MDD judged to be at higher risk for relapse due to unstable or partial remission (N=172) were randomized to 8 months of C-CT or fluoxetine with clinical management and assessed, free from protocol treatment, for 24 additional months. Pre-continuation-treatment characteristics that in survival analyses moderated treatments' effects on relapse over 8 months of continuation-phase treatment (residual symptoms and negative temperament) and on relapse/recurrence over the full observation period's 32 months (residual symptoms and age) were combined to estimate the potential advantage of C-CT versus fluoxetine for individual patients. Assigning patients to optimal continuation treatment (i.e., to C-CT or fluoxetine, depending on patients' pre-continuation-treatment characteristics) resulted in absolute reduction of relapse or recurrence risk by 16-21% compared to the other non-optimal treatment. Although these novel results require replication before clinical application, selecting optimal continuation treatment (i.e., personalizing treatment) for higher risk A-CT responders may decrease risks of MDD relapse and recurrence substantively.
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Affiliation(s)
- Jeffrey R. Vittengl
- Department of Psychology, Truman State University, Kirksville, MO, USA,Correspondence to: Jeffrey R. Vittengl, Department of Psychology, Truman State University, 100 East Normal Street, Kirksville, MO 63501-4221, USA, 1-660-785-6041, ; or, Robin B. Jarrett, Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9149, USA, 1-214-648-5345.
| | - Lee Anna Clark
- Department of Psychology, University of Notre Dame, Notre Dame, IN, USA
| | - Michael E. Thase
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robin B. Jarrett
- Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, TX, USA,Correspondence to: Jeffrey R. Vittengl, Department of Psychology, Truman State University, 100 East Normal Street, Kirksville, MO 63501-4221, USA, 1-660-785-6041, ; or, Robin B. Jarrett, Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9149, USA, 1-214-648-5345.
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Hollon SD, Thase ME, Markowitz JC. Treatment and Prevention of Depression. Psychol Sci Public Interest 2017; 3:39-77. [DOI: 10.1111/1529-1006.00008] [Citation(s) in RCA: 292] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
| | - Michael E. Thase
- University of Pittsburgh Medical Center and Western Psychiatric Institute and Clinic
| | - John C. Markowitz
- Weill Medical College of Cornell University and New York State Psychiatric Institute
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Cristea IA, Gentili C, Pietrini P, Cuijpers P. Sponsorship bias in the comparative efficacy of psychotherapy and pharmacotherapy for adult depression: meta-analysis. Br J Psychiatry 2017; 210:16-23. [PMID: 27810891 DOI: 10.1192/bjp.bp.115.179275] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 03/06/2016] [Accepted: 06/25/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Sponsorship bias has never been investigated for non-pharmacological treatments like psychotherapy. AIMS We examined industry funding and author financial conflict of interest (COI) in randomised controlled trials directly comparing psychotherapy and pharmacotherapy in depression. METHOD We conducted a meta-analysis with subgroup comparisons for industry v. non-industry-funded trials, and respectively for trial reports with author financial COI v. those without. RESULTS In total, 45 studies were included. In most analyses, pharmacotherapy consistently showed significant effectiveness over psychotherapy, g = -0.11 (95% CI -0.21 to -0.02) in industry-funded trials. Differences between industry and non-industry-funded trials were significant, a result only partly confirmed in sensitivity analyses. We identified five instances where authors of the original article had not reported financial COI. CONCLUSIONS Industry-funded trials for depression appear to subtly favour pharmacotherapy over psychotherapy. Disclosure of all financial ties with the pharmaceutical industry should be encouraged.
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Affiliation(s)
- Ioana A Cristea
- Ioana A. Cristea, Department of Clinical Psychology and Psychotherapy, Babes Bolyai University, Cluj-Napoca, Romania, and Department of General Psychology, University of Padova, Padova, Italy; Claudio Gentili, Department of General Psychology, University of Padova, Padova, Italy, Pietro Pietrini, IMT Institute for Advanced Studies, Lucca, Italy; Pim Cuijpers, Department of Clinical Psychology, VU University and EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
| | - Claudio Gentili
- Ioana A. Cristea, Department of Clinical Psychology and Psychotherapy, Babes Bolyai University, Cluj-Napoca, Romania, and Department of General Psychology, University of Padova, Padova, Italy; Claudio Gentili, Department of General Psychology, University of Padova, Padova, Italy, Pietro Pietrini, IMT Institute for Advanced Studies, Lucca, Italy; Pim Cuijpers, Department of Clinical Psychology, VU University and EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
| | - Pietro Pietrini
- Ioana A. Cristea, Department of Clinical Psychology and Psychotherapy, Babes Bolyai University, Cluj-Napoca, Romania, and Department of General Psychology, University of Padova, Padova, Italy; Claudio Gentili, Department of General Psychology, University of Padova, Padova, Italy, Pietro Pietrini, IMT Institute for Advanced Studies, Lucca, Italy; Pim Cuijpers, Department of Clinical Psychology, VU University and EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
| | - Pim Cuijpers
- Ioana A. Cristea, Department of Clinical Psychology and Psychotherapy, Babes Bolyai University, Cluj-Napoca, Romania, and Department of General Psychology, University of Padova, Padova, Italy; Claudio Gentili, Department of General Psychology, University of Padova, Padova, Italy, Pietro Pietrini, IMT Institute for Advanced Studies, Lucca, Italy; Pim Cuijpers, Department of Clinical Psychology, VU University and EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
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Abstract
BACKGROUND Depressive illness is common in old age. Prevalence in the community of case level depression is around 15% and milder forms of depression are more common. It causes significant distress and disability. The number of people over the age of 60 years is expected to double by 2050 and so interventions for this often long-term and recurrent condition are increasingly important. The causes of late-life depression differ from depression in younger adults and so it is appropriate to study it separately.This is an update of a Cochrane review first published in 2012. OBJECTIVES To examine the efficacy of antidepressants and psychological therapies in preventing the relapse and recurrence of depression in older people. SEARCH METHODS We performed a search of the Cochrane Common Mental Disorders Group's specialised register (the CCMDCTR) to 13 July 2015. The CCMDCTR includes relevant randomised controlled trials (RCTs) from the following bibliographic databases: The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We also conducted a cited reference search on 13 July 2015 of the Web of Science for citations of primary reports of included studies. SELECTION CRITERIA Both review authors independently selected studies. We included RCTs involving people aged 60 years and over successfully treated for an episode of depression and randomised to receive continuation and maintenance treatment with antidepressants, psychological therapies, or a combination. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data. The primary outcome for benefit was recurrence rate of depression (reaching a cut-off on any depression rating scale) at 12 months and the primary outcome for harm was drop-outs at 12 months. Secondary outcomes included relapse/recurrence rates at other time points, global impression of change, social functioning, and deaths. We performed meta-analysis using risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, with 95% confidence intervals (CI). MAIN RESULTS This update identified no further trials. Seven studies from the previous review met the inclusion criteria (803 participants). Six compared antidepressant medication with placebo; two involved psychological therapies. There was marked heterogeneity between the studies.Comparing antidepressants with placebo on the primary outcome for benefit, there was a statistically significant difference favouring antidepressants in reducing recurrence compared with placebo at 12 months with a GRADE rating of low for quality of evidence (three RCTs, n = 247, RR 0.67, 95% CI 0.54 to 0.82; number needed to treat for an additional beneficial outcome (NNTB) 5). Comparing antidepressants with placebo on the primary outcome for harms, there was no difference in drop-out rates at 12 months' follow-up, with a GRADE rating of low.There was no significant difference between psychological treatment and antidepressant in recurrence rates at 12 months (one RCT, n = 53) or between combination treatment and antidepressant alone at 12 months. AUTHORS' CONCLUSIONS This updated Cochrane review supports the findings of the original 2012 review. The long-term benefits and harm of continuing antidepressant medication in the prevention of recurrence of depression in older people are not clear and no firm treatment recommendations can be made on the basis of this review. Continuing antidepressant medication for 12 months appears to be helpful with no increased harms; however, this was based on only three small studies, relatively few participants, use of a range of antidepressant classes, and clinically heterogeneous populations. Comparisons at other time points did not reach statistical significance.Data on psychological therapies and combined treatments were too limited to draw any conclusions on benefits and harms.The quality of the evidence used in reaching these conclusions was low and the review does not, therefore, offer clear guidance to clinicians and patients on best practice and matching interventions to particular patient characteristics.Of note, we identified no new studies that evaluated pharmacological or psychological interventions in the continuation and maintenance treatment of depression in older people. We are aware of studies conducted since the previous review that included both older people and adults under the age of 65 years, but these fall outside of the remit of this review. We believe that there remains a need for studies solely recruiting older people, particularly the 'older old' with comorbid medical problems. However, these studies are likely to be challenging to conduct and may not, so far, have been prioritised by funders.
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Affiliation(s)
- Philip Wilkinson
- University of Oxford, Warneford HospitalDepartment of PsychiatryOxfordUKOX3 7JX
- Fulbrook Centre, Churchill HospitalOxford Health NHS Foundation TrustOxfordUKOX3 7JU
| | - Zehanah Izmeth
- John Radcliffe HospitalOxford University Hospitals NHS Foundation TrustOxfordUK
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Vittengl JR, Clark LA, Thase ME, Jarrett RB. Predictors of longitudinal outcomes after unstable response to acute-phase cognitive therapy for major depressive disorder. ACTA ACUST UNITED AC 2016; 52:268-77. [PMID: 25985046 DOI: 10.1037/pst0000021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
After patients with major depressive disorder (MDD) respond to acute-phase cognitive therapy (CT), continuation-phase treatments may be applied to improve long-term outcomes. We clarified which CT responders experience remission, recovery, relapse, and recurrence by testing baseline demographic, clinical, and personality variables. The sample of CT responders at higher risk of relapse (N = 241) was randomized to 8 months of continuation-phase CT, double-blinded fluoxetine, or pill placebo, and followed 24 months (Jarrett & Thase, 2010). Patients with lower positive emotionality and behavioral activation at the end of acute-phase CT showed increased risk for relapse/recurrence of MDD. In addition, patients with lower positive emotionality and behavioral activation, as well as higher residual depression (including emotional, cognitive, and social facets), showed decreased probability of remission (≥6 continuous weeks of minimal or absent symptoms) after acute-phase CT. Finally, patients with greater residual depression, as well as younger age and earlier MDD onset, showed decreased probability of recovery (≥35 continuous weeks of minimal or absent symptoms) after acute-phase CT. Moderator analyses did not reveal differential prediction across the continuation phase treatment arms. These results may help clinicians gauge the prognoses and need for continuation treatment among MDD patients who respond to acute-phase CT.
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Affiliation(s)
| | | | - Michael E Thase
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania
| | - Robin B Jarrett
- Department of Psychiatry, The University of Texas Southwestern Medical Center
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14
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Abstract
The high prevalence, frequent relapse, and recurrence of major depressive disorder (MDD) increase its personal and societal costs. Cognitive therapy (CT) aims to decrease depressive symptoms and prevent relapse/recurrence. We review prevention evidence for acute, continuation, and maintenance CTs for patients whose depression is active, remitted, and recovered, respectively. Evidence suggests that patients relapse less often after discontinuing acute phase CT versus discontinuing pharmacotherapy. Continuation CT further decreases relapse relative to inactive controls and similarly to active pharmacotherapy. Maintenance CT may decrease recurrence but needs rigorous evaluation. Post-acute CT's preventive effects appear greater for higher-risk patients (e.g., with residual depressive symptoms, unstable acute-phase treatment response, childhood trauma, more prior depressive episodes), although risks may vary by specific CTs.
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Affiliation(s)
- Jeffrey R. Vittengl
- Department of Psychology, Truman State University, 100 East Normal Street, Kirksville, MO 63501-4221, USA. Telephone: 660-785-6041
| | - Robin B. Jarrett
- Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9149, USA. Telephone: 214-648-5345
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15
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Cuijpers P, Karyotaki E, Andersson G, Li J, Mergl R, Hegerl U. The effects of blinding on the outcomes of psychotherapy and pharmacotherapy for adult depression: A meta-analysis. Eur Psychiatry 2015; 30:685-93. [PMID: 26169475 DOI: 10.1016/j.eurpsy.2015.06.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 06/13/2015] [Accepted: 06/14/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Randomized trials with antidepressants are often run under double blind placebo-controlled conditions, whereas those with psychotherapies are mostly unblinded. This can introduce bias in favor of psychotherapy when the treatments are directly compared. In this meta-analysis, we examine this potential source of bias. METHODS We searched Pubmed, PsycInfo, Embase and the Cochrane database (1966 to January 2014) by combining terms indicative of psychological treatment and depression, and limited to randomized trials. We included 35 trials (with 3721 patients) in which psychotherapy and pharmacotherapy for adult depression were directly compared with each other. We calculated effect sizes for each study indicating the difference between psychotherapy and pharmacotherapy at post-test. Then, we examined the difference between studies with a placebo condition and those without in moderator analyses. RESULTS We did not find a significant difference between the studies with and those without a placebo condition. The studies in which a placebo condition was included indicated no significant difference between psychotherapy and pharmacotherapy (g=-0.07; NNT=25). Studies in which no placebo condition was included (and patients and clinicians in both conditions were not blinded), resulted in a small, but significant difference between psychotherapy and pharmacotherapy in favor of pharmacotherapy (g=-0.13; NNT=14). CONCLUSIONS Studies comparing psychotherapy and pharmacotherapy in which both groups of patients (and therapists) are not blinded (no placebo condition is included) result in a very small, but significantly higher effect for pharmacotherapy.
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Affiliation(s)
- P Cuijpers
- Department of clinical psychology, VU University Amsterdam, 1, Van der Boechorststraat, 1081 BT Amsterdam, The Netherlands; EMGO Institute for Health and Care Research, The Netherlands.
| | - E Karyotaki
- Department of clinical psychology, VU University Amsterdam, 1, Van der Boechorststraat, 1081 BT Amsterdam, The Netherlands; EMGO Institute for Health and Care Research, The Netherlands
| | - G Andersson
- Department of behavioural sciences and learning, Swedish institute for disability research, Linköping University, Sweden; Department of clinical neuroscience, psychiatry section, Karolinska Institutet, Stockholm, Sweden
| | - J Li
- Key laboratory of mental health, institute of psychology, Chinese academy of sciences, Beijing, China
| | - R Mergl
- Department of psychiatry and psychotherapy, university of Leipzig, Leipzig, Germany
| | - U Hegerl
- Department of psychiatry and psychotherapy, university of Leipzig, Leipzig, Germany
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16
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Biesheuvel-Leliefeld KEM, Kok GD, Bockting CLH, Cuijpers P, Hollon SD, van Marwijk HWJ, Smit F. Effectiveness of psychological interventions in preventing recurrence of depressive disorder: meta-analysis and meta-regression. J Affect Disord 2015; 174:400-10. [PMID: 25553400 DOI: 10.1016/j.jad.2014.12.016] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 12/02/2014] [Accepted: 12/04/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND Major depression is probably best seen as a chronically recurrent disorder, with patients experiencing another depressive episode after remission. Therefore, attention to reduce the risk of relapse or recurrence after remission is warranted. The aim of this review is to meta-analytically examine the effectiveness of psychological interventions to reduce relapse or recurrence rates of depressive disorder. METHODS We systematically reviewed the pertinent trial literature until May 2014. The random-effects model was used to compute the pooled relative risk of relapse or recurrence (RR). A distinction was made between two comparator conditions: (1) treatment-as-usual and (2) the use of antidepressants. Other sources of heterogeneity in the data were explored using meta-regression. RESULTS Twenty-five randomised trials met inclusion criteria. Preventive psychological interventions were significantly better than treatment-as-usual in reducing the risk of relapse or recurrence (RR=0.64, 95% CI=0.53-0.76, z=4.89, p<0.001, NNT=5) and also more successful than antidepressants (RR=0.83, 95% CI=0.70-0.97, z=2.40, p=0.017, NNT=13). Meta-regression showed homogeneity in effect size across a range of study, population and intervention characteristics, but the preventive effect of psychological intervention was usually better when the prevention was preceded by treatment in the acute phase (b=-1.94, SEb=0.68, z=-2.84, p=0.005). LIMITATIONS Differences between the primary studies in methodological design, composition of the patient groups and type of intervention may have caused heterogeneity in the data, but could not be evaluated in a meta-regression owing to poor reporting. CONCLUSIONS We conclude that there is supporting evidence that preventive psychological interventions reduce the risk of relapse or recurrence in major depression.
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Affiliation(s)
- Karolien E M Biesheuvel-Leliefeld
- Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands.
| | - Gemma D Kok
- Department of Clinical and Experimental Psychology, Groningen University, Groningen, The Netherlands
| | - Claudi L H Bockting
- Department of Clinical Psychology, EMGO Institute for Health and Care Research, VU University and VU University Medical Centre, Amsterdam, The Netherlands
| | - Pim Cuijpers
- Department of Clinical Psychology, EMGO Institute for Health and Care Research, VU University and VU University Medical Centre, Amsterdam, The Netherlands; Leuphana University, Lüneburg, Germany
| | - Steven D Hollon
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Harm W J van Marwijk
- Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands
| | - Filip Smit
- Department of Clinical Psychology, EMGO Institute for Health and Care Research, VU University and VU University Medical Centre, Amsterdam, The Netherlands; Department of Public Mental Health, Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, The Netherlands; Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands
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17
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The Treatment of Posttraumatic Stress Disorder and Related Psychosocial Consequences of Burn Injury. J Burn Care Res 2015; 36:184-92. [DOI: 10.1097/bcr.0000000000000177] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Collins M, Carey TA. Identification of Real and Artifactual Moderators of Effect Size in Meta-Analysis. MULTIVARIATE BEHAVIORAL RESEARCH 2015; 50:109-125. [PMID: 26609746 DOI: 10.1080/00273171.2014.963193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
This article argues that while meta-analytic studies are widely used in psychological literature, heterogeneity and the potential for confounding remain major problems in the interpretation of meta-analytic study results. The article demonstrates the use of exploratory analysis including graphical methods prior to meta-analysis, and introduces a methodology to screen for artifactual effects. These procedures are illustrated on effect size data comparing depression treatment outcome from psychotherapy versus pharmacotherapy. Results support prior findings of a nonsignificant difference in effect size between the two treatments. They also support findings that treatment type accounts for only a very small proportion of outcome variance. However, the results indicate that some previously reported covariates of depression treatment outcome may be artifactual.
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Affiliation(s)
- Mark Collins
- a Center of Applied Psychology , University of Canberra
| | - Timothy A Carey
- b Centre for Remote Health , A Joint Centre of Flinders University and Charles Darwin University
- c Central Australian Mental Health Service, NT Department of Health and Families
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Vasileva AV, Karavaeva TA, Poltorak SV, Chekhlaty EI. [The use of spitomine (buspirone) in the combined therapy of panic disorder]. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:63-71. [PMID: 26978053 DOI: 10.17116/jnevro201511511163-71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To explore the efficacy of spitomine (buspirone) in the combined therapy of panic disorder, we studied the dynamics of clinical parameters and personality traits associated with development and maintenance of panic disorder during the treatment. MATERIAL AND METHODS Thirty patients of a treatment setting for out-patients with panic disorder were enrolled in the study. Patients received combined treatment with spitomine (buspirone) in the dose of 30 mg/daily (10 mg three times a day) during 6 weeks and individual short-term direct cognitive-behavioral therapy. Anxiety and panic symptoms were measured with HARS, CGI, MADRS and STAI-A. RESULTS There was a significant reduction in panic and anxiety symptoms (by 50% on the HARS) that reached on average 9.73 scores to the end of the study. This finding indicates the absence of anxiety and, therefore, therapeutic efficacy of the treatment. Scores on state anxiety of STAI-A were significantly lower compared to baseline though the level of anxiety remained relatively high. The partial decrease in trait anxiety, though its level was high as well, was noted. CONCLUSION The combined therapy of panic disorder with spitomine (buspirone) and cognitive-behavioral therapy is an optimal treatment, though not without the limitations of short-term methods. Good tolerability of the drug allowed all patients to complete the study.
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Affiliation(s)
- A V Vasileva
- Bekhterev St. Petersburg Research Psychoneurological Institute, St. Petersburg, Russia
| | - T A Karavaeva
- Bekhterev St. Petersburg Research Psychoneurological Institute, St. Petersburg, Russia
| | - S V Poltorak
- Bekhterev St. Petersburg Research Psychoneurological Institute, St. Petersburg, Russia
| | - E I Chekhlaty
- Bekhterev St. Petersburg Research Psychoneurological Institute, St. Petersburg, Russia
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Vittengl JR, Clark LA, Thase ME, Jarrett RB. Stable remission and recovery after acute-phase cognitive therapy for recurrent major depressive disorder. J Consult Clin Psychol 2014; 82:1049-59. [PMID: 25045908 PMCID: PMC4244279 DOI: 10.1037/a0037401] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Continuation-phase cognitive therapy (C-CT) or fluoxetine (FLX) reduces relapse in adults with major depressive disorder (MDD; Jarrett, Minhajuddin, Gershenfeld, Friedman, & Thase, 2013). Among patients at higher risk for relapse, we hypothesized that continuation-phase treatment reduces residual symptoms and facilitates stable remission and recovery. METHOD Outpatients (N = 241) with recurrent MDD who responded to acute-phase CT with higher risk for relapse (i.e., had unstable remission defined by any of the last 7 acute-phase scores ≥ 7 using the Hamilton Rating Scale for Depression; Hamilton, 1960) were randomized to 8 months of C-CT, FLX, or pill placebo and followed for 24 additional months. Psychiatric status ratings (Keller et al., 1987) of 1 or 2 (absent or minimal depressive symptoms) for 6 and 35 continuous weeks post-randomization defined stable remission and recovery, respectively. RESULTS Actuarial estimates of stable remission (97%) and recovery (94%) by the end of follow-up were high and did not differ among groups. Observed (unadjusted) proportions of patients remitting (70%) and recovering (47%) before relapse or attrition were lower. During the continuation phase, C-CT (d = 0.21) and FLX (d = 0.25) patients had significantly lower mean depressive symptoms than did controls, but C-CT and FLX patients did not differ from each other, nor did the 3 experimental groups differ during follow-up. CONCLUSION Many patients who responded to CT with higher relapse risk subsequently remitted and recovered after discontinuation of acute-phase treatment. After discontinuation, C-CT and FLX decreased levels of residual depressive symptoms, but neither significantly increased the likelihood of stable remission or recovery, beyond the moderate to high levels observed among patients who did not relapse.
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Affiliation(s)
| | | | - Michael E Thase
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania
| | - Robin B Jarrett
- Department of Psychiatry, The University of Texas Southwestern Medical Center
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Leichsenring F, Schauenburg H. Empirically supported methods of short-term psychodynamic therapy in depression - towards an evidence-based unified protocol. J Affect Disord 2014; 169:128-43. [PMID: 25194781 DOI: 10.1016/j.jad.2014.08.007] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 07/22/2014] [Accepted: 08/04/2014] [Indexed: 12/28/2022]
Abstract
CONTEXT There is evidence that psychotherapy is helpful in depressive disorders, with no significant differences between psychotherapies. For psychodynamic therapy (PDT) various models prove to be efficacious. Thus, the evidence for PDT is "scattered" between different forms of PDT, also implying problems in training of psychotherapy and in transferring research to clinical practice. A unified protocol based on empirically-supported methods of PDT in depression may contribute to solve these problems METHODS Systematic search for randomized controlled trials fulfilling the following criteria: (a) individual psychodynamic therapy (PDT) of depressive disorders, (b) treatment manuals or manual-like guidelines, (c) PDT proved to be efficacious compared to control conditions, (d) reliable measures for diagnosis and outcome, and (f) adult patients. FINDINGS Fourteen RCTs fulfilled the inclusion criteria. By a systematic review of the applied methods of PDT seven treatment components were identified. A high consistency between components was found. The components were conceptualized in the form of seven interrelated treatment modules. CONCLUSIONS A unified psychodynamic protocol for depression may enhance the empirical status of PDT, facilitate both the training in psychotherapy and the transfer of research to clinical practice and may have an impact on the health care system.
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Affiliation(s)
- Falk Leichsenring
- Clinic of Psychosomatics and Psychotherapy, University of Giessen, Ludwigstrasse 76, 35392 Giessen, Germany.
| | - Henning Schauenburg
- Clinic for General Internal Medicine and Psychosomatics, University of Heidelberg, Germany
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Abstract
Approximately eight out of ten people experiencing a major depressive episode will have one or more further episodes during their lifetime: a recurrent major depressive disorder. Prolongation or lifelong pharmacotherapy has emerged as the main therapeutic tool for preventing relapse in depression. However, outcome after discontinuation of antidepressants does not seem to be affected by the duration of their administration. Loss of clinical effects, despite adequate compliance, has also emerged as a vexing clinical problem. Use of intermittent pharmacotherapy with follow-up visits is another therapeutic option that would leave patients with periods free of drugs and side effects, in consideration of the fact that a high proportion of patients would discontinue the antidepressant anyway. However, the problems of resistance (the fact that a drug treatment may be associated with a diminished chance of response in those patients who successfully responded to it, but discontinued it) and of discontinuation syndromes are a substantial disadvantage of this therapeutic option. In recent years, several controlled trials have suggested that a sequential use of pharmacotherapy in the treatment of the acute episode and psychotherapy in its residual phase may improve long-term outcome. However, patients should be motivated for psychotherapy and skilled therapists should be available. It is important to discuss with the patient the various therapeutic options and to adapt strategies to the specific needs of patients.
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Affiliation(s)
- Giovanni A Fava
- Department of Psychology, University of Bologna, Viale Berti Pichat 5,40127 Bologna, Italy.
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Bauer M, Pfennig A, Severus E, Whybrow PC, Angst J, Möller HJ. 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. World J Biol Psychiatry 2013; 14:334-85. [PMID: 23879318 DOI: 10.3109/15622975.2013.804195] [Citation(s) in RCA: 382] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Michael Bauer
- Department of Psychiatry and Psychotherapy, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany.
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Cuijpers P, Sijbrandij M, Koole SL, Andersson G, Beekman AT, Reynolds CF. The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: a meta-analysis of direct comparisons. World Psychiatry 2013; 12:137-48. [PMID: 23737423 PMCID: PMC3683266 DOI: 10.1002/wps.20038] [Citation(s) in RCA: 294] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Although psychotherapy and antidepressant medication are efficacious in the treatment of depressive and anxiety disorders, it is not known whether they are equally efficacious for all types of disorders, and whether all types of psychotherapy and antidepressants are equally efficacious for each disorder. We conducted a meta-analysis of studies in which psychotherapy and antidepressant medication were directly compared in the treatment of depressive and anxiety disorders. Systematic searches in bibliographical databases resulted in 67 randomized trials, including 5,993 patients that met inclusion criteria, 40 studies focusing on depressive disorders and 27 focusing on anxiety disorders. The overall effect size indicating the difference between psychotherapy and pharmacotherapy after treatment in all disorders was g=0.02 (95% CI: -0.07 to 0.10), which was not statistically significant. Pharmacotherapy was significantly more efficacious than psychotherapy in dysthymia (g=0.30), and psychotherapy was significantly more efficacious than pharmacotherapy in obsessive-compulsive disorder (g=0.64). Furthermore, pharmacotherapy was significantly more efficacious than non-directive counseling (g=0.33), and psychotherapy was significantly more efficacious than pharmacotherapy with tricyclic antidepressants (g=0.21). These results remained significant when we controlled for other characteristics of the studies in multivariate meta-regression analysis, except for the differential effects in dysthymia, which were no longer statistically significant.
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Affiliation(s)
- Pim Cuijpers
- Department of Clinical Psychology, VU University Amsterdam, Van der Boechorststraat 1, 1081, BT Amsterdam, The Netherlands; EMGO Institute for Health and Care Research, VU University and VU University Medical Center, Amsterdam, The Netherlands; Leuphana University, Lünebrug, Germany
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Abstract
OBJECTIVE To be used in conjunction with 'Pharmacological management of unipolar depression' [Malhi et al. Acta Psychiatr Scand 2013;127(Suppl. 443):6-23] and 'Lifestyle management of unipolar depression' [Berk et al. Acta Psychiatr Scand 2013;127(Suppl. 443):38-54]. To provide clinically relevant recommendations for the use of psychological treatments in depression derived from a literature review. METHOD Medical databases including MEDLINE and PubMed were searched for pertinent literature, with an emphasis on recent publications. RESULTS Structured psychological treatments such as cognitive behaviour therapy and interpersonal therapy (IPT) have a robust evidence base for efficacy in treating depression, even in severe cases of depression. However, they may not offer benefit as quickly as antidepressants, and maximal efficacy requires well-trained and experienced therapists. These therapies are effective across the lifespan and may be preferred where it is desired to avoid pharmacotherapy. In some instances, combination with pharmacotherapy may enhance outcome. Psychological therapy may have more enduring protective effects than medication and be effective in relapse prevention. Newer structured psychological therapies such as mindfulness-based cognitive therapy and acceptance and commitment therapy lack an extensive outcome literature, but the few published studies yielding positive outcomes suggest they should be considered options for treatment. CONCLUSION Cognitive behaviour therapy and IPT can be effective in alleviating acute depression for all levels of severity and in maintaining improvement. Psychological treatments for depression have demonstrated efficacy across the lifespan and may present a preferred treatment option in some groups, for example, children and adolescents and women who are pregnant or postnatal.
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Affiliation(s)
- L Lampe
- CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, Sydney, NSW, Australia.
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Abstract
BACKGROUND Depressive illness in older people causes significant suffering and health service utilisation. Relapse and recurrence rates are high. OBJECTIVES To examine the efficacy of antidepressants and psychological therapies in preventing the relapse and recurrence of depression in older people. SEARCH METHODS Search of the Cochrane Depression, Anxiety and Neurosis Review Group's specialized register (the CCDANCTR) up to 22 June 2012. The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE, (1974 to date) MEDLINE (1950 to date) and PsycINFO (1967 to date). We handsearched relevant journals, contacted experts in the field and examined reference lists, conference proceedings and bibliographies. SELECTION CRITERIA Both review authors independently selected studies. We included randomised controlled trials (RCTs) involving people aged 60 and over successfully treated for an episode of depression and randomised to receive continuation and maintenance treatment with antidepressants, psychological therapies, or combination. DATA COLLECTION AND ANALYSIS Data were extracted independently by the two authors.The primary outcome was relapse/recurrence rate of depression (reaching a cut-off on any depression rating scale) at six-monthly intervals. Secondary outcomes included global impression of change, social functioning, and deaths. Meta-analysis was performed using risk ratio for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals. MAIN RESULTS Seven studies met the inclusion criteria (803 participants). Six compared antidepressant medication with placebo; two involved psychological therapies. There was marked heterogeneity between the studies.Comparing antidepressants with placebo, at six months follow-up there was no significant difference. At 12 months follow-up there was a statistically significant difference favouring antidepressants in reducing recurrence compared with placebo (three RCTs, N = 247, RR = 0.67, 95% CI 0.55 to 0.82; NNTB = five). At 24 months there was no significant difference for antidepressants overall, however, for the subgroup of tricyclic antidepressants there was significant benefit (three RCTs, N = 169, RR = 0.70, 95% CI 0.50 to 0.99; NNTB = five). At 36 months there was no significant difference for antidepressants overall. There was no difference in treatment acceptability or death rates between antidepressant and placebo.There was no significant difference between psychological treatment and antidepressant in recurrence rates at 12, 24, and 36 months (one RCT, N = 53) or between combination and antidepressant alone.Overall, the included studies were at low risk of bias. AUTHORS' CONCLUSIONS The long-term benefits of continuing antidepressant medication in the prevention of recurrence of depression in older people are not clear and no firm treatment recommendations can be made on the basis of this review. Continuing antidepressant medication for 12 months appears to be helpful but this is based on only three small studies with relatively few participants using differing classes of antidepressants in clinically heterogeneous populations. Comparisons at other time points did not reach statistical significance. Data on psychological therapies and combined treatments are too limited to draw any conclusions.
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Abstract
Given the limitations of evidence for treatment options that are consistently effective for TRD and the possibility that TRD is in fact a form of depression that has a low probability of resolving, how can clinicians help patients with TRD? Perhaps the most important conceptual shift that needs to take place before treatment can be helpful is to accept TRD as a chronic illness, an illness similar to many others, one that can be effectively managed but that is not, at our present level of knowledge, likely to be cured. An undue focus on remission or even a 50% diminution of symptoms sets unrealistic goals for both patients and therapists and may lead to overtreatment and demoralization. The focus should be less on eliminating depressive symptoms and more on making sense of and learning to function better in spite of them. It is important to acknowledge the difficult nature of the depressive illness, to remove blame from the patient and clinician for not achieving remission, to set realistic expectations, and to help promote better psychosocial functioning even in the face of persisting symptoms. The critical element when implementing such an approach is a judicious balance between maintaining hope for improvement without setting unrealistic expectations. It is important to reemphasize that following a disease management model with acceptance of the reality of a chronic illness is not nihilistic and does not mean the abandonment of hope for improvement. The first step in treating a patient with TRD is to perform a comprehensive assessment of the patient’s past and current treatment history to ensure that evidence-based treatment trials have in fact been undertaken, and if not, such treatment trials should be implemented. If the patient continues to have significant residual symptoms, it is important to determine the impact is of these symptoms on the patient’s quality of life and ability to function. It is also important to evaluate the factors that may be contributing to the persistence of depressive symptoms such as comorbid personality disorders, somatic disorders, substance abuse, and work and interpersonal conflicts. The treatment of patients with TRD needs to move beyond attempts to modify symptoms without taking into consideration and attempting to modify the patient’s personality, coping skills, and social system. Further somatic treatment trials can be undertaken, if desired by the patient and therapist, as a small (5%–15%) percentage of patients may respond and further treatment trials, and this may engender hope. The risk with this approach is that patients and therapists may not work at disease management skills if they believe there may be a resolution of the depression if they could just find the right medication or intervention. Therapists may also feel pressured by patients, families, insurance companies, as well as their own sense of helplessness to escalate treatment in a more and more aggressive manner in an attempt to achieve an elusive remission. A disease management program can provide the therapist and patient with sufficient structure, skills, and goals to encourage ongoing treatment without resorting to unproven measures that may create more side effects and problems. It is particularly important to include the patient’s significant others in the reformulation of the patient’s problem and thereby learn how to manage the illness more effectively. Significant others and family members can be invaluable in providing support for dealing with the difficult process of acquiring a new skill set. Indeed, they spend significantly more time with the patient than does any therapist. Family members are likely to provide this kind of support only if they have been part of the assessment and treatment process. Patients with a wide range of chronic medical illnesses can and do learn to function effectively and to achieve a satisfying quality of life in spite of their illness. There is no reason to think that patients with TRD should not be able to achieve a similar level of illness management, functioning, and quality of life.
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Affiliation(s)
- Gabor I Keitner
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02912, USA.
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Stecker T, McGovern MP, Herr B. An intervention to increase alcohol treatment engagement: a pilot trial. J Subst Abuse Treat 2011; 43:161-7. [PMID: 22138200 DOI: 10.1016/j.jsat.2011.10.028] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Revised: 09/26/2011] [Accepted: 10/25/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Previous research has documented the difficulty individuals with alcohol use disorders have initiating alcohol treatment. This study assessed the feasibility of a brief, cognitive-behavioral intervention designed to increase treatment initiation among individuals with alcohol use disorders. METHODS This randomized controlled trial included 196 participants who screened positive for a possible alcohol use disorder on the alcohol use disorders identification test. Randomly assigned intervention participants were administered a brief cognitive-behaviorally-based intervention by telephone designed to modify beliefs that may interfere with treatment-seeking behavior. Beliefs about treatment and treatment-seeking behavior were assessed postintervention. RESULTS Participants receiving the intervention had significantly improved their attitudes toward addiction treatment (p < .002) and increased their reported intention-to-seek treatment (p < .000) postintervention. Further, intervention participants were almost three times more likely to attend treatment within a 3-month period (odds ratio = 2.60, p < .025) than participants in the control group. CONCLUSIONS A brief, cognitive-behavioral intervention delivered by telephone and focused on modifying treatment-interfering beliefs holds promise for increasing alcohol treatment seeking among individuals in need.
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Affiliation(s)
- Tracy Stecker
- Psychiatric Research Center, Dartmouth Medical School, Lebanon, NH 03766, USA.
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Relapse and recurrence prevention in depression: current research and future prospects. Clin Psychol Rev 2011; 31:1349-60. [PMID: 22020371 DOI: 10.1016/j.cpr.2011.09.003] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 08/08/2011] [Accepted: 09/10/2011] [Indexed: 11/22/2022]
Abstract
There is a growing body of literature which indicates that acute phases of psychotherapy are often ineffective in preventing relapse and recurrence in major depression. As a result, there is a need to develop and evaluate therapeutic approaches which aim to reduce the risk of relapse. This article provides a review of the empirical studies which have tested the prophylactic effects of therapy (cognitive-behavioral, mindfulness-based, and interpersonal psychotherapy) targeting relapse and recurrence in major depression. For definitional clarity, relapse is defined here as a return to full depressive symptomatology before an individual has reached a full recovery, whereas recurrence in defined as the onset of a new depressive episode after a full recovery has been achieved. Psychotherapeutic efforts to prevent relapse and recurrence in depression have been effective to varying degrees, and a number of variables appear to moderate the success of these approaches. A consistent finding has been that preventive cognitive-behavioral and mindfulness-based therapies are most effective for patients with three or more previous depressive episodes, and alternative explanations for this finding are discussed. It is noted, however, that a number of methodological limitations exist within this field of research, and so a set of hypotheses that may guide future studies in this area is provided.
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Wetherell JL, Stoddard JA, White KS, Kornblith S, Nguyen H, Andreescu C, Zisook S, Lenze EJ. Augmenting antidepressant medication with modular CBT for geriatric generalized anxiety disorder: a pilot study. Int J Geriatr Psychiatry 2011; 26:869-75. [PMID: 20872925 PMCID: PMC4070295 DOI: 10.1002/gps.2619] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Accepted: 07/19/2010] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Generalized anxiety disorder (GAD) is a prevalent psychiatric condition in older adults with deleterious effects on health and cognition. Although selective serotonin reuptake inhibitor (SSRI) medications have some efficacy as acute treatments for geriatric GAD, incomplete response is the most common outcome of monotherapy. We therefore developed a novel sequential treatment strategy, using personalized, modular cognitive-behavioral therapy (mCBT) to augment SSRI medication. METHOD In an open label pilot study (N = 10), subjects received a sequenced trial of 12 weeks of escitalopram followed by 16 weeks of escitalopram augmented with mCBT. We also examined the maintenance effects of mCBT over a 28-week follow-up period following drug discontinuation and termination of psychotherapy. RESULTS Results suggest that (1) adding mCBT to escitalopram significantly reduced anxiety symptoms and pathological worry, resulting in full remission for most patients and (2) some patients maintained response after all treatments were withdrawn. CONCLUSION Findings suggest that mCBT may be an effective augmentation strategy when added to SSRI medication and provide limited support for the long-term benefit of mCBT after discontinuation of pharmacotherapy.
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Affiliation(s)
- Julie Loebach Wetherell
- VA San Diego Healthcare System, San Diego, California, USA; Department of Psychiatry, University of California, San Diego, La Jolla, California, USA.
| | - Jill A. Stoddard
- Department of Psychology, Alliant International University, San Diego, California, USA
| | - Kamila S. White
- Department of Psychology, University of Missouri, St. Louis, Missouri, USA
| | - Sander Kornblith
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hoang Nguyen
- VA San Diego Healthcare System, San Diego, California, USA,Department of Psychiatry, University of California, San Diego, La Jolla, California, USA
| | - Carmen Andreescu
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sidney Zisook
- VA San Diego Healthcare System, San Diego, California, USA,Department of Psychiatry, University of California, San Diego, La Jolla, California, USA
| | - Eric J. Lenze
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
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Roshanaei-Moghaddam B, Pauly MC, Atkins DC, Baldwin SA, Stein MB, Roy-Byrne P. Relative effects of CBT and pharmacotherapy in depression versus anxiety: is medication somewhat better for depression, and CBT somewhat better for anxiety? Depress Anxiety 2011; 28:560-7. [PMID: 21608087 DOI: 10.1002/da.20829] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Revised: 04/09/2011] [Accepted: 04/18/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Little is known about whether cognitive behavioral therapy (CBT) or pharmacotherapy is relatively more advantageous for depressive versus anxiety disorders. METHODS We conducted a meta-analysis wherein we searched electronic databases and references to select randomized controlled studies comparing CBT and pharmacotherapy, with or without placebo, in adults with major depressive or anxiety disorders. The primary effect size was calculated from disorder-specific outcome measures as the difference between CBT and pharmacotherapy outcomes (i.e., positive effect size favors CBT; negative effect size favors pharmacotherapy). RESULTS Twenty-one anxiety (N = 1,266) and twenty-one depression (N = 2,027) studies comparing medication to CBT were included. Including all anxiety disorders, the overall effect size was.25 (95% CI: -0.02, 0.55, P =.07). Effects for panic disorder significantly favored CBT over medications (.50, 95% CI: 0.02, 0.98). Obsessive-compulsive disorder showed similar effects-sizes, though not statistically significant (.49, 95% CI: -0.11, 1.09). Medications showed a nonsignificant advantage for social anxiety disorder (-.22, 95% CI: -0.50, 0.06). The overall effect size for depression studies was.05 (95% CI: -0.09, 0.19), with no advantage for medications or CBT. Pooling anxiety disorder and depression studies, the omnibus comparison of the relative difference between anxiety and depression in effectiveness for CBT versus pharmacotherapy pointed to a nonsignificant advantage for CBT in anxiety versus depression (B =.14, 95% CI: -0.14, 0.43). CONCLUSIONS On balance, the evidence presented here indicates that there are at most very modest differences in effects of CBT versus pharmacotherapy in the treatment of anxiety versus depressive disorders. There seems to be larger differences between the anxiety disorders in terms of their relative responsiveness to pharmacotherapy versus CBT.
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Oestergaard S, Møldrup C. Optimal duration of combined psychotherapy and pharmacotherapy for patients with moderate and severe depression: a meta-analysis. J Affect Disord 2011; 131:24-36. [PMID: 20950863 DOI: 10.1016/j.jad.2010.08.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Revised: 08/17/2010] [Accepted: 08/17/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND To investigate the most effective duration of combined psychotherapy and pharmacotherapy for achieving remission and preventing relapse in depressive patients as compared to pharmacotherapy alone. METHODS A systematic review of English articles using PubMed, EMBASE, Web of Science, the Cochrane Library, and PsychINFO was performed in September 2009. Clinical studies comparing pharmacotherapy alone with pharmacotherapy in combination with a psychological intervention for depression treatment that reported response, remission or relapse as outcomes were included in the analysis. For each of the studies, clinical binary outcomes such as response, remission or relapse were extracted. RESULTS All pooled analyses were based on random-effects models. Twenty-one article describing the influence of additional psychotherapy on remission and 15 articles reporting the influence on relapse in depression were included in the analysis. Patients receiving combined treatment experienced remission more often than those receiving pharmacotherapy alone, with the highest odds ratio OR, 2.36; 95% CI, 1.58-3.55 observed at 4months after commencing the treatment. Patients receiving pharmacotherapy alone also demonstrated a higher risk for relapse compared to those receiving combined treatment. LIMITATIONS We restricted our search to only English language publications. Studies investigating relapse or recurrence rates are often of small size. CONCLUSION Pharmacotherapy enhanced with psychotherapy is associated with a higher probability of remission and a lower risk of relapse, as compared to antidepressants alone for depression treatment. Receiving psychotherapy in both the acute and continuation phases is the most effective option. Further research is needed to investigate the influence of additional psychotherapy on different patients.
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Affiliation(s)
- Svetlana Oestergaard
- Department of Pharmacology and Pharmacotherapy, Section for Social Pharmacy, University of Copenhagen, Faculty of Pharmaceutical Sciences, Denmark.
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Trivedi RB, Nieuwsma JA, Williams JW. Examination of the utility of psychotherapy for patients with treatment resistant depression: a systematic review. J Gen Intern Med 2011; 26:643-50. [PMID: 21184287 PMCID: PMC3101965 DOI: 10.1007/s11606-010-1608-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 08/05/2010] [Accepted: 12/03/2010] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To examine the utility of psychotherapy in managing treatment resistant depression. DATA SOURCES PubMed, PsycInfo, Embase, Cochrane Registry of Controlled Clinical Trials, article bibliographies. REVIEW METHODS Eligible articles had to be in English and include English-speaking adult outpatients from general medical or mental health clinics. Studies had to be randomized clinical trials (RCT) involving at least one of the following psychotherapy modalities: cognitive therapy, interpersonal therapy, or behavior therapy. Patients were considered treatment resistant if they reported partial or no remission following treatment with an adequate antidepressant dose for ≥ 6 weeks. Exclusion criteria included receiving psychotherapy at the time of recruitment, and/or comorbid psychiatric conditions unlikely to be treated outside of specialized mental health care (e.g., severe substance abuse). Due to heterogeneity in study designs, a summary estimate of effect was not calculated. Studies were critically analyzed and a qualitative synthesis was conducted. RESULTS Of 941 original titles, 13 articles evaluating 7 unique treatment comparisons were included. Psychotherapy was examined as an augmentation to antidepressants in five studies and as substitution treatment in two studies. A total of 592 patients were evaluated (Mean age ~40 y; Females = 50-85%; Caucasians ≥ 75%). The STAR*D trial used an equipoise stratified randomization design; the remaining studies were RCTs. Compared to active management, two good quality trials showed similar benefit from augmenting antidepressants with psychotherapy; one fair quality and one poor quality trial showed benefit from psychotherapy augmentation; and one good and one poor trial found similar benefit from substituting psychotherapy for antidepressants. One fair quality trial showed lithium augmentation to be more beneficial than psychotherapy. CONCLUSIONS Review demonstrates the utility of psychotherapy in managing treatment resistant depression. However, evidence is sparse and results are mixed. Given that quality trials are lacking, rigorous clinical trials are recommended to guide practice. In the interim, primary care providers should consider psychotherapy when treating patients with treatment resistant depression.
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Affiliation(s)
- Ranak B Trivedi
- VA Puget Sound Health Care System, University of Washington School of Public Health, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA.
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Lopez MA, Basco MR. Feasibility of dissemination of cognitive behavioral therapy to Texas community mental health centers. J Behav Health Serv Res 2011; 38:91-104. [PMID: 20162373 DOI: 10.1007/s11414-009-9209-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
State mental health systems are actively seeking to disseminate empirically supported treatment approaches to improve the outcomes of adults with serious mental illnesses. However, many of these interventions have not been studied within public mental health settings. Cognitive behavioral therapy (CBT) has been shown to be effective for major depression in well-controlled trials, but its effectiveness in public mental health settings is less known. The present study examines the feasibility of dissemination of CBT in the Texas public mental health system. Seven clinicians were trained by a CBT expert and supervised for 5 months, during which time their skills approached competency levels of therapists in randomized controlled trials. Forty clients were treated during the therapists' training phase, attending an average of ten sessions and experiencing a significant reduction in depressive symptoms. Study results are compared with previously published studies of CBT.
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Affiliation(s)
- Molly A Lopez
- Addiction Research Institute, University of Texas at Austin, School of Social Work, 1717 W. 6th Street, Suite 335, Austin, TX 78703, USA.
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Guidi J, Fava GA, Fava M, Papakostas GI. Efficacy of the sequential integration of psychotherapy and pharmacotherapy in major depressive disorder: a preliminary meta-analysis. Psychol Med 2011; 41:321-331. [PMID: 20444307 DOI: 10.1017/s0033291710000826] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Prevention of relapse and recurrence represents an important task in the successful treatment of major depressive disorder (MDD). The aim of this meta-analysis was to examine the efficacy of the sequential integration of psychotherapy and pharmacotherapy in reducing the risk of relapse and recurrence in MDD. METHOD Keyword searches were conducted in Medline, EMBASE, PsycINFO and the Cochrane Library from inception of each database to December 2008. Randomized controlled trials examining the efficacy of the administration of psychotherapy after successful response to acute-phase pharmacotherapy in the treatment of adults with MDD were considered for inclusion in the meta-analysis. RESULTS Eight high-quality studies with 442 patients in a sequential treatment arm and 433 in a control treatment arm were included. The pooled risk ratio (RR) for relapse/recurrence was 0.797 [95% confidence interval (CI) 0.659-0.964] according to the random-effects model, suggesting a relative advantage in preventing relapse/recurrence for the sequential administration of treatments compared with control conditions. Performing subgroup analyses, we found a trend favoring psychotherapy during continuation of antidepressant drugs compared to antidepressants or treatment as usual (RR 0.842, 95% CI 0.674-1.051). Patients randomized to psychotherapy while antidepressants were discontinued were significantly less likely to experience relapse/recurrence compared to controls (RR 0.650, 95% CI 0.463-0.912). CONCLUSIONS We found evidence that the sequential integration of psychotherapy and pharmacotherapy is a viable strategy for preventing relapse and recurrence in MDD. In addition, our findings suggest that discontinuation of antidepressant drugs may be feasible when psychotherapy is provided.
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Affiliation(s)
- J Guidi
- Affective Disorders Program, Department of Psychology, University of Bologna, Italy.
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Gustafson DH, Shaw BR, Isham A, Baker T, Boyle MG, Levy M. Explicating an evidence-based, theoretically informed, mobile technology-based system to improve outcomes for people in recovery for alcohol dependence. Subst Use Misuse 2011; 46:96-111. [PMID: 21190410 PMCID: PMC3179272 DOI: 10.3109/10826084.2011.521413] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Post-treatment relapse to uncontrolled alcohol use is common. Currently available communication technology can use existing models for relapse prevention to cost-effectively improve long-term relapse prevention. This paper describes: (1) research-based elements of alcohol consumption-related relapse prevention and how they can be encompassed in self-determination theory (SDT) and Marlatt's cognitive behavioral relapse prevention model, (2) how technology could help address the needs of people seeking recovery, (3) a technology-based prototype, organized around sexual transmitted disease and Marlatt's model, and (4) how we are testing a system based on the ideas in this article and related ethical and operational considerations.
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Affiliation(s)
- David H. Gustafson
- Network for the Improvement of Addiction Treatment, University of Wisconsin-Madison
| | - Bret R. Shaw
- Department of Life Sciences Communication, 316 Hiram Smith Hall, 1545 Observatory Drive, University of Wisconsin–Madison, Madison, WI 53706, Tel: 608-890-1878
| | - Andrew Isham
- Network for the Improvement of Addiction Treatment, University of Wisconsin–Madison
| | - Timothy Baker
- Department of Psychology, University of Wisconsin–Madison
| | | | - Michael Levy
- CAB Health & Recovery Services, Peabody, Massachusetts
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Hollon SD, Ponniah K. A review of empirically supported psychological therapies for mood disorders in adults. Depress Anxiety 2010; 27:891-932. [PMID: 20830696 PMCID: PMC2948609 DOI: 10.1002/da.20741] [Citation(s) in RCA: 138] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The mood disorders are prevalent and problematic. We review randomized controlled psychotherapy trials to find those that are empirically supported with respect to acute symptom reduction and the prevention of subsequent relapse and recurrence. METHODS We searched the PsycINFO and PubMed databases and the reference sections of chapters and journal articles to identify appropriate articles. RESULTS One hundred twenty-five studies were found evaluating treatment efficacy for the various mood disorders. With respect to the treatment of major depressive disorder (MDD), interpersonal psychotherapy (IPT), cognitive behavior therapy (CBT), and behavior therapy (BT) are efficacious and specific and brief dynamic therapy (BDT) and emotion-focused therapy (EFT) are possibly efficacious. CBT is efficacious and specific, mindfulness-based cognitive therapy (MBCT) efficacious, and BDT and EFT possibly efficacious in the prevention of relapse/recurrence following treatment termination and IPT and CBT are each possibly efficacious in the prevention of relapse/recurrence if continued or maintained. IPT is possibly efficacious in the treatment of dysthymic disorder. With respect to bipolar disorder (BD), CBT and family-focused therapy (FFT) are efficacious and interpersonal social rhythm therapy (IPSRT) possibly efficacious as adjuncts to medication in the treatment of depression. Psychoeducation (PE) is efficacious in the prevention of mania/hypomania (and possibly depression) and FFT is efficacious and IPSRT and CBT possibly efficacious in preventing bipolar episodes. CONCLUSIONS The newer psychological interventions are as efficacious as and more enduring than medications in the treatment of MDD and may enhance the efficacy of medications in the treatment of BD.
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Affiliation(s)
- Steven D Hollon
- Department of Psychology, Vanderbilt University, Nashville, Tennessee 37203, USA.
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Cognitive behaviour therapy for withdrawal from antidepressant medication: a single case series. Behav Cogn Psychother 2010; 39:77-97. [PMID: 20849682 DOI: 10.1017/s1352465810000512] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Research has clearly established the efficacy of pharmacotherapy and cognitive behaviour therapy (CBT) for depression. There is less literature addressing cessation of treatment, such as relapse during withdrawal from antidepressant medication. AIMS The current study examines the role of psychological constructs that may influence relapse or fear of relapse and lead to resumption of medication. This hypothesizes that during withdrawal individuals may misinterpret normal variations in mood and dysphoric or other symptoms as reduced levels of medication in their bodies in keeping with a simplistic rationale for antidepressants. METHOD The study uses an intensive single case AB style design in three cases during the withdrawal process. All participants had been treated with CBT plus antidepressants and had previously attempted to withdraw from antidepressants. The first part of the study naturalistically tracks belief changes as medication decreases; the second examines changes in these if/when a CBT intervention is introduced due to relapse or potential near-relapse. Daily self-monitoring diaries were used to measure target variables, together with standardized questionnaires up to 6 months follow-up. RESULTS Changes in symptoms, appraisal of symptoms, and beliefs about medication changed throughout the study. All participants remained medication free at 6 months follow-up. Two cases received CBT intervention due to possible relapse; the third underwent an unproblematic withdrawal. CONCLUSIONS Patterns of change are discussed in terms of current approaches to medication cessation and the role of CBT during withdrawal.
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Driessen E, Hollon SD. Cognitive behavioral therapy for mood disorders: efficacy, moderators and mediators. Psychiatr Clin North Am 2010; 33:537-55. [PMID: 20599132 PMCID: PMC2933381 DOI: 10.1016/j.psc.2010.04.005] [Citation(s) in RCA: 171] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cognitive behavioral therapy (CBT) is efficacious in the acute treatment of depression and may provide a viable alternative to antidepressant medication (ADM) for even more severely depressed unipolar patients when implemented in a competent fashion. CBT also may be of use as an adjunct to medication treatment of bipolar patients, although there have been few studies and they are not wholly consistent. CBT does seem to have an enduring effect that protects against subsequent relapse and recurrence following the end of active treatment, which is not the case for medications. Single studies that require replication suggest that patients who are married or unemployed or who have more antecedent life events may do better in CBT than in ADM, as might patients who are free from comorbid Axis II disorders, whereas patients with comorbid Axis II disorders seem to do better in ADM than in CBT. There also are indications that CBT may work through processes specified by theory to produce change in cognition that in turn mediate subsequent change in depression and freedom from relapse following treatment termination, although evidence in that regard is not yet conclusive.
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Affiliation(s)
- Ellen Driessen
- Faculty of Psychology and Education, Department of Clinical Psychology, VU University Amsterdam, Van der Boechorststraat 1, 1018 BX Amsterdam, The Netherlands.
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Abstract
The sequential model of treatment for depression, i.e. the use of psychotherapy in patients who have remitted from a major depressive disorder after a course of pharmacotherapy, is an intensive two-stage approach that derives from the awareness that one course of treatment is unlikely to provide a solution to all the symptoms of patients. The aim of the sequential approach is to provide different types of treatment for as long as considered necessary in different phases of illness as determined by repeated assessments. The treatment strategies are chosen on the basis of the symptoms identified and not as predefined options. The sequential model emphasizes consideration of subclinical and residual symptomatology according to the organizing principles of macro-analysis (a relationship between co-occurring symptoms and problems is established on the basis of where treatment should commence in the first place). Diagnostic endpoints (i.e. DSM diagnoses), the customary guidance of treatment planning, are replaced by conceptualization of disorders as 'transfer stations', which are amenable to longitudinal verification and modification. The aim of this systematic review was to survey the literature concerned with the sequential approach to the treatment of depression. Randomized controlled trials were identified using MEDLINE and a manual search of the literature. In seven of the eight studies that were identified, the sequential use of pharmacotherapy and psychotherapy was found to improve long-term outcome after termination of treatment compared with clinical management and treatment as usual. Nevertheless, data on this approach are limited and more studies are necessary for detailing the various clinical steps associated with it. The sequential approach calls for a re-assessment of the design of comparative clinical trials. It allows randomization of patients who are already in treatment and assignment of them to treatment alternatives according to stages of development of their illness and not simply to disease classification. The model is thus more in line with the chronicity of mood disorders compared to the standard randomized controlled trial, which is based on the acute disease model.
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Affiliation(s)
- Giovanni A Fava
- Affective Disorders Program and Laboratory of Experimental Psychotherapy, Department of Psychology, University of Bologna, Bologna, Italy.
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Insulin resistance, obesity, inflammation, and depression in polycystic ovary syndrome: biobehavioral mechanisms and interventions. Fertil Steril 2010; 94:1565-74. [PMID: 20471009 DOI: 10.1016/j.fertnstert.2010.03.081] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Accepted: 03/30/2010] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To summarize physiological and psychological characteristics that are common among women diagnosed with polycystic ovary syndrome (PCOS) and provide evidence suggesting that addressing psychological disturbances can reduce or alleviate physical symptoms of PCOS through behavioral pathways and physiological pathways. METHOD(S) Empirical studies and expert consensuses pertaining to physiological, psychological, and medical management aspects of PCOS were identified and presented in this review. Articles were identified by searching Pubmed, PsycInfo, Medline ISI, CINAHL, or a Web browser (i.e., Google) using numerous combinations of terms pertaining to physiological, psychological, and medical management aspects of PCOS. An article was chosen to be included in this review if it reported findings and/or provided information that related to and helped support the main purpose(s) of this review article. RESULT(S) Available literature on the physiological (i.e., hyperandrogenism, central obesity, inflammation, insulin resistance) and psychological (i.e., depression, anxiety, eating disorders) factors among women with PCOS provides evidence that these various aspects of PCOS are strongly interrelated. CONCLUSION(S) The existence of these relationships among physiological and psychological factors strongly suggests that medical management of PCOS would greatly benefit from inclusion of psychological and behavioral approaches.
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Abstract
OBJECTIVE To estimate the efficacy of acupuncture for depression during pregnancy in a randomized controlled trial. METHODS A total of 150 pregnant women who met Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria for major depressive disorder were randomized to receive either acupuncture specific for depression or one of two active controls: control acupuncture or massage. Treatments lasted 8 weeks (12 sessions). Junior acupuncturists, who were not told about treatment assignment, needled participants at points prescribed by senior acupuncturists. All treatments were standardized. The primary outcome was the Hamilton Rating Scale for Depression, administered by masked raters at baseline and after 4 and 8 weeks of treatment. Continuous data were analyzed using mixed effects models and by intent to treat. RESULTS Fifty-two women were randomized to acupuncture specific for depression, 49 to control acupuncture, and 49 to massage. Women who received acupuncture specific for depression experienced a greater rate of decrease in symptom severity (P<.05) compared with the combined controls (Cohen's d=0.39, 95% confidence interval [CI] 0.01-0.77) or control acupuncture alone (P<.05; Cohen's d=0.46, 95% CI 0.01-0.92). They also had significantly greater response rate (63.0%) than the combined controls (44.3%; P<.05; number needed to treat, 5.3; 95% CI 2.8-75.0) and control acupuncture alone (37.5%; P<.05: number needed to treat, 3.9; 95% CI 2.2-19.8). Symptom reduction and response rates did not differ significantly between controls (control acupuncture, 37.5%; massage, 50.0%). CONCLUSION The short acupuncture protocol demonstrated symptom reduction and a response rate comparable to those observed in standard depression treatments of similar length and could be a viable treatment option for depression during pregnancy. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov, www.clinicaltrials.gov, NCT00186654.
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Fournier JC, DeRubeis RJ, Shelton RC, Hollon SD, Amsterdam JD, Gallop R. Prediction of response to medication and cognitive therapy in the treatment of moderate to severe depression. J Consult Clin Psychol 2010; 77:775-87. [PMID: 19634969 DOI: 10.1037/a0015401] [Citation(s) in RCA: 227] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A recent randomized controlled trial found nearly equivalent response rates for antidepressant medications and cognitive therapy in a sample of moderate to severely depressed outpatients. In this article, the authors seek to identify the variables that were associated with response across both treatments as well as variables that predicted superior response in one treatment over the other. The sample consisted of 180 depressed outpatients: 60 of whom were randomly assigned to cognitive therapy; 120 were assigned to antidepressant medications. Treatment was provided for 16 weeks. Chronic depression, older age, and lower intelligence each predicted relatively poor response across both treatments. Three prescriptive variables-marriage, unemployment, and having experienced a greater number of recent life events-were identified, and each predicted superior response to cognitive therapy relative to antidepressant medications. Thus, 6 markers of treatment outcome were identified, each of which might be expected to carry considerable clinical utility. The 3 prognostic variables identify subgroups that might benefit from alternative treatment strategies; the 3 prescriptive variables identify groups who appear to respond particularly well to cognitive therapy.
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Affiliation(s)
- Jay C Fournier
- Department of Psychology, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Sado M, Knapp M, Yamauchi K, Fujisawa D, So M, Nakagawa A, Kikuchi T, Ono Y. Cost-effectiveness of combination therapy versus antidepressant therapy for management of depression in Japan. Aust N Z J Psychiatry 2009; 43:539-47. [PMID: 19440886 DOI: 10.1080/00048670902873664] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Major depression is expected to become the second leading contributor to disease burden worldwide by 2020. Only a few studies, however, have compared the cost-effectiveness of a combination of cognitive behavioural therapy and antidepressant therapy versus antidepressant therapy alone. The purpose of the present study was therefore to analyse cost-effectiveness, from the perspective of the health-care system and also from a social perspective, comparing combined cognitive behavioural therapy + antidepressant therapy and antidepressant therapy alone in the Japanese setting. METHOD A formal decision analytical model was constructed. The analyses were performed from both the perspective of the health-care system and the societal perspective. The clinical outcomes were determined from published articles and reports of expert panels. Because no patient-level data were available, deterministic costing of the different treatment strategies was carried out. Cost-effectiveness was assessed first by determining the incremental cost-effectiveness ratio (ICER) per successfully treated patient, and then by the ICER per quality-adjusted life years (QALYs). RESULTS The combined therapy increased the rate of successfully treated patients, QALY of severe depression and QALY of moderate depression by 0.15, 0.08 and 0.04, respectively. The combined therapy proved to be more expensive from the health-care system perspective, but the incremental costs were completely offset by the considerable reduction of productivity loss from the social perspective. From the health-care perspective, the ICER per successfully treated patient, ICER per QALY of severe depression and ICER per QALY of moderate depression were JPY 140,418, JPY 268,550 and JPY 537,100, respectively. All the ICERs appeared to be negative from the social perspective. CONCLUSION The combined therapy appeared to be cost-effective from the health-care system perspective and the dominant strategy from the social perspective.
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Affiliation(s)
- Mitsuhiro Sado
- Department of Neuropsychiatry, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan.
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Harkness EF, Bower PJ. On-site mental health workers delivering psychological therapy and psychosocial interventions to patients in primary care: effects on the professional practice of primary care providers. Cochrane Database Syst Rev 2009; 2009:CD000532. [PMID: 19160181 PMCID: PMC7068168 DOI: 10.1002/14651858.cd000532.pub2] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Mental health problems are common in primary care and mental health workers (MHWs) are increasingly working in this setting delivering psychological therapy and psychosocial interventions to patients. In addition to treating patients directly, the introduction of on-site MHWs represents an organisational change that may lead to changes in the clinical behaviour of primary care providers (PCPs). OBJECTIVES To assess the effects of on-site MHWs delivering psychological therapy and psychosocial interventions in primary care on the clinical behaviour of primary care providers (PCPs). SEARCH STRATEGY The following sources were searched in 1998: the Cochrane Effective Practice and Organisation of Care Group Specialised Register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE, PsycINFO, CounselLit, NPCRDC skill-mix in primary care bibliography, and reference lists of articles. Additional searches were conducted in February 2007 using the following sources: MEDLINE, EMBASE, PsycINFO, CINAHL, and Cochrane Central Register of Clinical Trials (CENTRAL) (The Cochrane Library). SELECTION CRITERIA Randomised trials, controlled before and after studies, and interrupted time series analyses of MHWs working alongside PCPs in primary care settings. The outcomes included objective measures of PCP behaviours such as consultation rates, prescribing, and referral. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality. MAIN RESULTS Forty-two studies were included in the review. There was evidence that MHWs caused significant reductions in PCP consultations (standardised mean difference -0.17, 95% CI -0.30 to -0.05), psychotropic prescribing (relative risk 0.67, 95% CI 0.56 to 0.79), prescribing costs (standardised mean difference -0.22, 95% CI -0.38 to -0.07), and rates of mental health referral (relative risk 0.13, 95% CI 0.09 to 0.20) for the patients they were seeing. In controlled before and after studies, the addition of MHWs to a practice did not affect prescribing behaviour towards the wider practice population and there was no consistent pattern to the impact on referrals in the wider patient population. AUTHORS' CONCLUSIONS This review provides some evidence that MHWs working in primary care to deliver psychological therapy and psychosocial interventions cause a significant reduction in PCP behaviours such as consultations, prescribing, and referrals to specialist care. However, the changes are modest in magnitude, inconsistent, do not generalise to the wider patient population, and their clinical or economic significance is unclear.
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Affiliation(s)
- Elaine F Harkness
- University of ManchesterNational Primary Care Research and Development CentreWilliamson BuildingOxford RoadManchesterUKM13 9PL
| | - Peter J Bower
- University of ManchesterNational Primary Care Research and Development CentreWilliamson BuildingOxford RoadManchesterUKM13 9PL
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de Maat S, Dekker J, Schoevers R, van Aalst G, Gijsbers-van Wijk C, Hendriksen M, Kool S, Peen J, Van R, de Jonghe F. Short psychodynamic supportive psychotherapy, antidepressants, and their combination in the treatment of major depression: a mega-analysis based on three randomized clinical trials. Depress Anxiety 2008; 25:565-74. [PMID: 17557313 DOI: 10.1002/da.20305] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The efficacy of Short Psychodynamic Supportive Psychotherapy (SPSP) has not yet been compared with pharmacotherapy. A mega-analysis based on three original Randomized Clinical Trials (RCTs) was performed. Patients with (mild to moderate) major depressive disorder were randomized in (24 weeks) SPSP (n = 97), pharmacotherapy (n = 45), or their combination (n = 171). Efficacy was assessed by the Hamilton Depression Rating Scale (HDRS), Clinical Global Impression of Severity and of Improvement (CGI-S), the Symptom Checklist (SCL; depression subscale) and the Quality of Life Depression Scale (QLDS). Pearson chi(2) calculations were used to compare success rates. Analyses of covariance (ANCOVAs) were used to test inter-group differences. Success rates indicated that independent observers (HDRS) found no differences in symptom reduction between SPSP and pharmacotherapy (P = 0.214), but therapists (CGI-S, P = 0.026), and patients (SCL, P = 0.036) favored SPSP. Combined therapy was found superior to pharmacotherapy by all three (patients (P = 0.000), therapists (P = 0.024), independent observers (P = 0.024)). Independent observers (P = 0.062) and therapists (P = 0.430) found no differences between combined therapy and SPSP, but patients (P = 0.016) found combined therapy to be superior. As far as quality of life is concerned, success rates indicated that patients (QLDS) found no differences between SPSP and pharmacotherapy (P = 0.073) or between SPSP and combined therapy (P = 0.217). However, they found combined therapy superior to pharmacotherapy (P = 0.015). The results of the mega-analysis suggest that combined therapy is more efficacious than pharmacotherapy. SPSP and pharmacotherapy seem equally efficacious, except for some indications that patients and therapists favor SPSP for symptom reduction. Combined therapy and SPSP also seem equally efficacious, except that patients think that the first is better in symptom reduction.
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Affiliation(s)
- Saskia de Maat
- Depression Research Group of the Mentrum Institute for Mental Health, Free University, Amsterdam, The Netherlands
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