Cognitive-Behavioral Analysis System of Psychotherapy as a Maintenance Treatment for Chronic Depression

Development and validation of Unsuccessful Disengagement Aging Scale (UDAS) for older adults

The present study aimed to develop a precise and reliable measure of unsuccessful disengagement among older adults, defined as involuntary withdrawal from societal roles and norms due to familial or societal pressure, resulting in the transfer of responsibilities to the younger generation. High scores on the Unsuccessful Disengagement Aging Scale (UDAS) were indicative of a greater degree of unsuccessful disengagement. The study was conducted in two parts: Study I involved a purposive sample of 200 participants, whereas Study II involved a purposive sample of 500 occupationally retired older adults aged between 65 and 85 years. The constructs of the study were measured using the UDAS, Depression Anxiety and Stress Scale, and Identity and Experiences Scale. In Study I, the UDAS was subjected to an Exploratory Factor Analysis, which revealed a clear four-factor solution with high factor loadings and internally consistent factors. This factor structure was confirmed through Confirmatory Factor Analysis in Study II. Construct validity was established through the UDAS's significant positive correlation with depression and non-significant correlation with assimilation identity style. Furthermore, the mean UDAS score of older adults suffering from chronic physical ailments such as hypertension, diabetes, cardiac problems, hepatitis, ulcers, liver problems, arthritis, and joint pain was significantly higher than that of healthy older adults, indicating the concurrent validity of the UDAS in distinguishing between ill and healthy older adults. Overall, the results indicated that the UDAS was a reliable and valid instrument for measuring unsuccessful disengagement in older adults.

Psychological interventions to prevent relapse in anxiety and depression: A systematic review and meta-analysis

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.

Static and treatment-responsive brain biomarkers of depression relapse vulnerability following prophylactic psychotherapy: Evidence from a randomized control trial

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A prospective study of neural biomarkers of relapse in remitted depressed patients.

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Assessed neural response to dysphoric mood-induction before and after psychotherapy.

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Relapse over a 2-year follow-up linked to dysphoria-evoked sensory inhibition.

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Relapse risk was lower when dorsolateral prefrontal reactivity decreased over time.

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Depression prophylaxis may involve reducing dysphoria-evoked sensory inhibition.

Background

Neural reactivity to dysphoric mood induction indexes the tendency for distress to promote cognitive reactivity and sensory avoidance. Linking these responses to illness prognosis following recovery from Major Depressive Disorder informs our understanding of depression vulnerability and provides engagement targets for prophylactic interventions.

Methods

A prospective fMRI neuroimaging design investigated the relationship between dysphoric reactivity and relapse following prophylactic intervention. Remitted depressed outpatients (N = 85) were randomized to 8 weeks of Cognitive Therapy with a Well-Being focus or Mindfulness Based Cognitive Therapy. Participants were assessed before and after therapy and followed for 2 years to assess relapse status. Neural reactivity common to both assessment points identified static biomarkers of relapse, whereas reactivity change identified dynamic biomarkers.

Results

Dysphoric mood induction evoked prefrontal activation and sensory deactivation. Controlling for past episodes, concurrent symptoms and medication status, somatosensory deactivation was associated with depression recurrence in a static pattern that was unaffected by prophylactic treatment, HR 0.04, 95% CI [0.01, 0.14], p < .001. Treatment-related prophylaxis was linked to reduced activation of the left lateral prefrontal cortex (LPFC), HR 3.73, 95% CI [1.33, 10.46], p = .013. Contralaterally, the right LPFC showed dysphoria-evoked inhibitory connectivity with the right somatosensory biomarker

Conclusions

These findings support a two-factor model of depression relapse vulnerability, in which: enduring patterns of dysphoria-evoked sensory deactivation contribute to episode return, but vulnerability may be mitigated by targeting prefrontal regions responsive to clinical intervention. Emotion regulation during illness remission may be enhanced by reducing prefrontal cognitive processes in favor of sensory representation and integration.

A Patient Stratification Approach to Identifying the Likelihood of Continued Chronic Depression and Relapse Following Treatment for Depression

Background: Subgrouping methods have the potential to support treatment decision making for patients with depression. Such approaches have not been used to study the continued course of depression or likelihood of relapse following treatment. Method: Data from individual participants of seven randomised controlled trials were analysed. Latent profile analysis was used to identify subgroups based on baseline characteristics. Associations between profiles and odds of both continued chronic depression and relapse up to one year post-treatment were explored. Differences in outcomes were investigated within profiles for those treated with antidepressants, psychological therapy, and usual care. Results: Seven profiles were identified; profiles with higher symptom severity and long durations of both anxiety and depression at baseline were at higher risk of relapse and of chronic depression. Members of profile five (likely long durations of depression and anxiety, moderately-severe symptoms, and past antidepressant use) appeared to have better outcomes with psychological therapies: antidepressants vs. psychological therapies (OR (95% CI) for relapse = 2.92 (1.24–6.87), chronic course = 2.27 (1.27–4.06)) and usual care vs. psychological therapies (relapse = 2.51 (1.16–5.40), chronic course = 1.98 (1.16–3.37)). Conclusions: Profiles at greater risk of poor outcomes could benefit from more intensive treatment and frequent monitoring. Patients in profile five may benefit more from psychological therapies than other treatments.

Efficacy of a Specialized Group Intervention for Compulsive Exercise in Inpatients with Anorexia Nervosa: A Randomized Controlled Trial

INTRODUCTION

Treatment of compulsive exercise is recognized as a key unmet challenge in the treatment of anorexia nervosa (AN). To address this challenge, we developed the manualized group intervention "healthy exercise behavior" (HEB). This study evaluates the efficacy of HEB for the reduction of compulsive exercise as add-on to routine inpatient treatment (treatment as usual [TAU]) in a randomized controlled trial.

METHODS

Two hundred and seven adolescent and adult female inpatients with (atypical) AN were randomly allocated to TAU or to additional participation in HEB (TAU + HEB). HEB integrates elements of exercise-based therapy into a cognitive-behavioral approach. Assessments took place at admission, pre-intervention, post-intervention, discharge, and 6 months follow-up. Primary outcome was the severity of compulsive exercise assessed by the Commitment to Exercise Scale between pre- and post-intervention; secondary outcomes were additional aspects of compulsive exercise, assessed by the Compulsive Exercise Test, weight gain, eating disorder and general psychopathology, and emotion regulation.

RESULTS

In intention-to-treat analysis for the primary outcome, the TAU + HEB group showed significantly stronger reductions in the severity of compulsive exercise compared to the TAU group (z = -2.81; p = 0.005; effect size [ES] = -0.3). We also found significantly stronger reductions from admission to discharge (z= 2.62; p = 0.009; ES = -0.43), and from admission to follow-up (z = 2.1; p = 0.035; ES = -0.39). Regarding secondary outcomes, we found significant group differences between pre- and post-intervention in additional aspects of compulsive exercise (z = -2.55; p = 0.011; ES = -0.27). We did not find significant differences regarding weight gain, eating disorder and general psychopathology, and emotion regulation.

CONCLUSIONS

Our intervention proved efficacious in reducing compulsive exercise in inpatients with (atypical) AN.

Characteristics of the Optimal Cognitive Behavioral Analysis System of Psychotherapy (CBASP) Therapist Role

The characteristics of the optimal CBASP therapist role for the treatment of the Persistent Depressive Disorder patient (chronic depression) is delineated in this paper. This paper contains the opinions and experiences of the creator of CBASP who has developed and revised the model over more than 4 decades. The paper is not a rigorous study nor a review of rigorous studies. The difficulties of the patient are briefly discussed and then the characteristics of the optimal clinical role are presented. The clinical role of CBASP, the only model to have been developed specifically to treat the chronically depressive patient, is unique in the field of psychotherapy. Four role categories describing the behavior of the best therapists are presented and discussed: (1) the therapist is able to enact a Disciplined Personal Involvement clinical role with the patient; (2) the therapist is able to implement an acquisition-learning approach to therapeutic administration; (3) the practitioner is able to adhere to the standards of CBASP technique administration; and finally, (4) the clinician is able to implement several facilitative interpersonal skills.

Review of dysthymia and persistent depressive disorder: history, correlates, and clinical implications

Persistent depressive disorder is a chronic mood disorder that is common and often more disabling than episodic major depression. In DSM-5, the term subsumes several chronic depressive presentations, including dysthymia with or without superimposed major depressive episodes, chronic major depression, and recurrent major depression without recovery between episodes. Dysthymia can be difficult to detect in psychiatric and primary care settings until it intensifies in the form of a superimposed major depressive episode. Although information is scarce concerning the cause of persistent depressive disorder including dysthymia, the causation is likely to be multifactorial. In this narrative Review, we discuss current knowledge about the nosology and neurobiological basis of dysthymia and persistent depressive disorder, emphasising a dimensional perspective based on course for further research. We also review new developments in psychotherapy and pharmacotherapy for persistent depressive disorder, and propose a tailored, modular approach to accommodate its multifaceted nature.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparative effectiveness of continuation and maintenance treatments for persistent depressive disorder in adults

BACKGROUND

Persistent depressive disorder (PDD) is defined as a depressive disorder with a minimum illness duration of two years, including four diagnostic subgroups (dysthymia, chronic major depression, recurrent major depression with incomplete remission between episodes, and double depression). Persistent forms of depression represent a substantial proportion of depressive disorders, with a lifetime prevalence ranging from 3% to 6% in the Western world. Growing evidence indicates that PDD responds well to several acute interventions, such as combined psychological and pharmacological treatments. Yet, given the high rates of relapse and recurrences of depression following response to acute treatment, long-term continuation and maintenance therapy are of great importance. To date, there has been no evidence synthesis available on continuation and maintenance treatments of PDDs.

OBJECTIVES

To assess the effects of pharmacological and psychological (either alone or combined) continuation and maintenance treatments for persistent depressive disorder, in comparison with each other, placebo (drug/attention placebo/non-specific treatment control), and treatment as usual (TAU). Continuation treatments are defined as treatments given to currently remitted people (remission is defined as depressive symptoms dropping below case level) or to people who previously responded to an antidepressant treatment. Maintenance therapy is given during recovery (which is defined as remission lasting longer than six months).

SEARCH METHODS

We searched Ovid MEDLINE (1950- ), Embase (1974- ), PsycINFO (1967- ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 28 September 2018. An earlier search of these databases was also conducted for RCTs via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to 11 Dec 2015). In addition we searched grey literature resources as well as the international trial registers ClinicalTrials.gov and ICTRP to 28 September 2018. We screened reference lists of included studies and contacted the first author of all included studies.

SELECTION CRITERIA

We included randomized (RCTs) and non-randomized controlled trials (NRCTs) in adults with formally diagnosed PDD, receiving pharmacological, psychological, or combined continuation and maintenance interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies and extracted and analyzed data. The primary efficacy outcome was relapse/recurrence rate of depression. The primary acceptance outcome was dropout due to any reason other than relapse/recurrence. We performed random-effects meta-analyses using risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI).

MAIN RESULTS

We included 10 studies (seven RCTs, three NRCTs) involving 840 participants in this review, from which five studies investigated continuation treatments and five studies investigated maintenance treatments. Overall, the included studies were at low-to-moderate risk of bias. For the three NRCTs, the most common source of risk of bias was selection of reported results. For the seven RCTs, the most common sources of risk of bias was non-blinding of outcome assessment and other bias (especially conflict of interest due to pharmaceutical sponsoring).Pharmacological continuation and maintenance therapiesThe most common comparison was antidepressant medication versus tablet placebo (five studies). Participants taking antidepressant medication were probably less likely to relapse or to experience a recurrent episode compared to participants in the placebo group at the end of the intervention (13.9% versus 33.8%, RR 0.41, 95% CI 0.21 to 0.79; participants = 383; studies = 4; I² = 54%, moderate quality evidence). Overall dropout rates may be similar between participants in the medication and placebo group (23.0% versus 25.5%, RR 0.90, 95% CI 0.39 to 2.11; RCTs = 4; participants = 386; I² = 64%, low quality evidence). However, sensitivity analyses showed that the primary outcome (rate of relapse/recurrence) showed no evidence of a difference between groups when only including studies with low risk of bias.None of the studies compared pharmacological or psychological treatments versus TAU.Psychological continuation and maintenance therapiesOne study compared psychological therapies versus attention placebo/non-specific control. One study compared psychotherapy with medication. The results of the studies including psychotherapy might indicate that continued or maintained psychotherapy could be a useful intervention compared to no treatment or antidepressant medication. However, the body of evidence for these comparisons was too small and uncertain to draw any high quality conclusions.Combined psychological and pharmacological continuation and maintenance therapiesThree studies compared combined psychological and pharmacological therapies with pharmacological therapies alone. One study compared combined psychological and pharmacological therapies with psychotherapeutic therapies alone. However, the body of evidence for these comparisons was too small and uncertain to draw any high quality conclusionsComparison of different antidepressant medications Two studies reported data on the direct comparison of two antidepressants. However, the body of evidence for this comparison was too small and uncertain to draw any high quality conclusions.

AUTHORS' CONCLUSIONS

Currently, it is uncertain whether continued or maintained pharmacotherapy (or both) with the reviewed antidepressant agents is a robust treatment for preventing relapse and recurrence in people with PDD, due to moderate or high risk of bias as well as clinical heterogeneity in the analyzed studies.For all other comparisons, the body of evidence was too small to draw any final conclusions, although continued or maintained psychotherapy might be effective compared to no treatment. There is need for more high quality trials of psychological interventions. Further studies should address health-related quality of life and adverse events more precisely, as well as assessing follow-up data.

Comparing the Efficacy of CBASP with Two Versions of CBT for Depression in a Routine Care Center: A Randomized Clinical Trial

BACKGROUND

The cognitive-behavioral analysis system of psychotherapy (CBASP) was developed for the treatment of chronic, early-onset depression. However, it is unclear whether this approach can be recommended for depression in general (episodic and chronic), and no direct comparisons between CBASP with different versions of cognitive-behavioral therapy (CBT) exist.

METHODS

A randomized controlled trial compared 3 treatment conditions (all lasting 16 sessions) with a waiting list group (WL): CBASP, CBT with a focus on physical exercise (CBT-E), and CBT with a focus on pleasurable, low-energy and mindful activities (CBT-M). We included 173 patients and involved 41 therapists. Assessments were at baseline, after session 8, and at the end of treatment.

RESULTS

Our primary outcome Beck Depression Inventory-II indicated a general advantage of the CBT arms compared to CBASP [F(6, 154.5) = 4.2, p = 0.001], with significant contrasts in particular in favor of CBT-E. Effect sizes against WL were d = 0.91 (CBT-E), 0.87 (CBT-M), and 0.47 (CBASP). A triple interaction with an additional factor "chronic versus episodic depression" [F(6, 142.7) = 2.2, p = 0.048] indicated that the treatments resulted in different outcomes, with best results again for CBT-E in particular in episodic depression. Responder rates indicated significant improvements (56% in both CBT arms, 34% in the CBASP arm, 3.4% in WL; intention-to-treat samples). As compared to CBASP, response rates were significantly higher for CBT-E (OR = 2.48; 95% CI = 1.02-6.00) and CBT-M (OR = 2.46; 95% CI = 1.01-6.01).

CONCLUSIONS

CBASP was more effective than WL, but less effective than the 2 CBT arms. This was mainly caused by an advantage of CBT interventions in episodic depression.

Follow-up of monotherapy remitters in the PReDICT study: Maintenance treatment outcomes and clinical predictors of recurrence

OBJECTIVE

This study followed remitted patients from a randomized controlled trial of adults with major depressive disorder (MDD). The aims were to describe rates of recurrence and to evaluate 3 clinical predictor domains.

METHOD

Ninety-four treatment-naïve patients (50% female; Mage = 38.1 years; 48.9% White; 30.9% Hispanic) with MDD who had remitted to 12-week monotherapy (escitalopram, duloxetine, or cognitive behavior therapy [CBT]) participated in a 21-month maintenance phase (i.e., continued medication or 3 possible CBT booster sessions per year). Recurrence was assessed quarterly, and the clinical predictors were the following: 2 measures of residual depressive symptoms, 1 measure of lifetime depressive episodes, and 2 measures of baseline anxiety. Survival analysis models evaluated recurrence rates, and regression models evaluated the predictors.

RESULTS

Among all patients, 15.5% experienced a recurrence, and the survival distributions did not statistically differ among treatments. Residual depressive symptoms on the Hamilton Depression Rating Scale at the end of monotherapy were associated with increased risk for recurrence (hazard ratio = 1.31, 95% confidence interval [CI: 1.02, 1.67], Wald χ2 = 4.41, p = .036), and not having a comorbid anxiety disorder diagnosis at study baseline reduced the risk of recurrence (hazard ratio = .31, 95% CI [.10, .94], Wald χ2 = 4.28, p = .039).

CONCLUSIONS

The study supported the benefits of maintenance treatment for treatment-naïve patients who remitted to initial monotherapy; nevertheless, remitted patients with a comorbid anxiety disorder diagnosis at the beginning of treatment or residual depressive symptoms after initial treatment were at risk for poorer long-term outcomes. (PsycINFO Database Record

Evidence-Based Applications of Combination Psychotherapy and Pharmacotherapy for Depression

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

European Psychiatric Association Guidance on psychotherapy in chronic depression across Europe

PURPOSE

Patients with chronic depression (CD) by definition respond less well to standard forms of psychotherapy and are more likely to be high utilizers of psychiatric resources. Therefore, the aim of this guidance paper is to provide a comprehensive overview of current psychotherapy for CD. The evidence of efficacy is critically reviewed and recommendations for clinical applications and research are given.

METHODS

We performed a systematic literature search to identify studies on psychotherapy in CD, evaluated the retrieved documents and developed evidence tables and recommendations through a consensus process among experts and stakeholders.

RESULTS

We developed 5 recommendations which may help providers to select psychotherapeutic treatment options for this patient group. The EPA considers both psychotherapy and pharmacotherapy to be effective in CD and recommends both approaches. The best effect is achieved by combined treatment with psychotherapy and pharmacotherapy, which should therefore be the treatment of choice. The EPA recommends psychotherapy with an interpersonal focus (e.g. the Cognitive Behavioural Analysis System of Psychotherapy [CBASP]) for the treatment of CD and a personalized approach based on the patient's preferences.

DISCUSSION

The DSM-5 nomenclature of persistent depressive disorder (PDD), which includes CD subtypes, has been an important step towards a more differentiated treatment and understanding of these complex affective disorders. Apart from dysthymia, ICD-10 still does not provide a separate entity for a chronic course of depression. The differences between patients with acute episodic depression and those with CD need to be considered in the planning of treatment. Specific psychotherapeutic treatment options are recommended for patients with CD.

CONCLUSION

Patients with chronic forms of depression should be offered tailored psychotherapeutic treatments that address their specific needs and deficits. Combination treatment with psychotherapy and pharmacotherapy is the first-line treatment recommended for CD. More research is needed to develop more effective treatments for CD, especially in the longer term, and to identify which patients benefit from which treatment algorithm.

Prevention of Relapse and Recurrence in Adults with Major Depressive Disorder: Systematic Review and Meta-Analyses of Controlled Trials

BACKGROUND

Findings of substantial remaining morbidity in treated major depressive disorder (MDD) led us to review controlled trials of treatments aimed at preventing early relapses or later recurrences in adults diagnosed with MDD to summarize available data and to guide further research.

METHODS

Reports (n = 97) were identified through systematic, computerized literature searching up to February 2015. Treatment versus control outcomes were summarized by random-effects meta-analyses.

RESULTS

In 45 reports of 72 trials (n = 14 450 subjects) lasting 33.4 weeks, antidepressants were more effective than placebos in preventing relapses (response rates [RR] = 1.90, confidence interval [CI]: 1.73-2.08; NNT = 4.4; p < 0.0001). In 35 reports of 37 trials (n = 7253) lasting 27.0 months, antidepressants were effective in preventing recurrences (RR = 2.03, CI 1.80-2.28; NNT = 3.8; p < 0.0001), with minor differences among drug types. In 17 reports of 22 trials (n = 1 969) lasting 23.7 months, psychosocial interventions yielded inconsistent or inconclusive results.

CONCLUSIONS

Despite evidence of the efficacy of drug treatment compared to placebos or other controls, the findings further underscore the substantial, unresolved morbidity in treated MDD patients and strongly encourage further evaluations of specific, improved individual and combination therapies (pharmacological and psychological) conducted over longer times, as well as identifying clinical predictors of positive or unfavorable responses and of intolerability of long-term treatments in MDD.

Interventions for preventing relapse or recurrence of depression in primary health care settings: A systematic review

OBJECTIVE

A systematic review was conducted to assess the efficacy of pharmacological and psychological interventions for preventing relapse or recurrence of depression in adults with depression in primary care.

METHOD

Papers published from inception to January 28th 2014 were identified searching the electronic databases MEDLINE, EMBASE, PsycINFO, and CENTRAL. Randomized controlled trials of any pharmacological, psychological or psychosocial intervention or combination of interventions delivered in primary care settings were included, with relapse or recurrence of a depressive disorder as a main outcome. The Cochrane Collaboration risk of bias tool was used to assess study quality.

RESULTS

Only three studies with a small number of patients fulfilled the inclusion criteria. None of the three randomized controlled trials included in our review showed a statistically significant superiority of an intervention for the prevention of depression relapse or recurrence.

CONCLUSIONS

There is limited evidence to inform relapse or recurrence prevention strategies specifically in primary care.

Can non-pharmacological interventions prevent relapse in adults who have recovered from depression? A systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To identify studies of non-pharmacological interventions provided following recovery from depression, and to evaluate their efficacy in preventing further episodes.

METHOD

We identified relevant randomised controlled trials from searching MEDLINE, Embase, PsycINFO, CENTRAL, and ProQuest, searching reference and citation lists, and contacting study authors. We conducted a meta-analysis of relapse outcomes.

RESULTS

There were 29 eligible trials. 27 two-way comparisons including 2742 participants were included in the primary analysis. At 12months cognitive-behavioural therapy (CBT), mindfulness-based cognitive therapy (MBCT), and interpersonal psychotherapy (IPT) were associated with a 22% reduction in relapse compared with controls (95% CI 15% to 29%). The effect was maintained at 24months for CBT, but not for IPT despite ongoing sessions. There were no 24-month MBCT data. A key area of heterogeneity differentiating these groups was prior acute treatment. Other psychological therapies and service-level programmes varied in efficacy.

CONCLUSION AND IMPLICATIONS

Psychological interventions may prolong the recovery a person has achieved through use of medication or acute psychological therapy. Although there was evidence that MBCT is effective, it was largely tested following medication, so its efficacy following psychological interventions is less clear. IPT was only tested following acute IPT. Further exploration of sequencing of interventions is needed.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO 2011:CRD42011001646.

Effectiveness of psychological interventions in preventing recurrence of depressive disorder: meta-analysis and meta-regression

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.

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

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

Cognitive-behavioral therapy as continuation treatment to sustain response after electroconvulsive therapy in depression: a randomized controlled trial

BACKGROUND

Although electroconvulsive therapy (ECT) is the most effective acute antidepressant intervention, sustained response rates are low. It has never been systematically assessed whether psychotherapy, continuation ECT, or antidepressant medication is the most efficacious intervention to maintain initial treatment response.

METHODS

In a prospective, randomized clinical trial, 90 inpatients with major depressive disorder (MDD) were treated with right unilateral ultra-brief acute ECT. Electroconvulsive therapy responders received 6 months guideline-based antidepressant medication (MED) and were randomly assigned to add-on therapy with cognitive-behavioral group therapy (CBT-arm), add-on therapy with ultra-brief pulse continuation electroconvulsive therapy (ECT-arm), or no add-on therapy (MED-arm). After the 6 months of continuation treatment, patients were followed-up for another 6 months. The primary outcome parameter was the proportion of patients who remained well after 12 months.

RESULTS

Of 90 MDD patients starting the acute phase, 70% responded and 47% remitted to acute ECT. After 6 months of continuation treatment, significant differences were observed in the three treatment arms with sustained response rates of 77% in the CBT-arm, 40% in the ECT-arm, and 44% in the MED-arm. After 12 months, these differences remained stable with sustained response rates of 65% in the CBT-arm, 28% in the ECT-arm, and 33% in the MED-arm.

CONCLUSIONS

These results suggest that ultra-brief pulse ECT as a continuation treatment correlates with low sustained response rates. However, the main finding implicates cognitive-behavioral group therapy in combination with antidepressants might be an effective continuation treatment to sustain response after successful ECT in MDD patients.

Stable remission and recovery after acute-phase cognitive therapy for recurrent major depressive disorder

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.

Effectiveness of cognitive behavior therapy for severe mood disorders in an acute psychiatric naturalistic setting: a benchmarking study

The current study examined the effectiveness of brief cognitive behavior therapy (CBT) for severe mood disorders in an acute naturalistic setting. The sample included 951 individuals with either major depressive disorder (n = 857) or bipolar disorder with depressed mood (n = 94). Participants completed a battery of self-report measures assessing depression, overall well-being, and a range of secondary outcomes both before and after treatment. We found significant reductions in depressive symptoms, worry, self-harm, emotional lability, and substance abuse, as well as significant improvements in well-being and interpersonal relationships, post-treatment. Comparable to outpatient studies, 30% of the sample evidenced recovery from depression. Comparison of findings to benchmark studies indicated that, although the current sample started treatment with severe depressive symptoms and were in treatment for average of only 10 days, the overall magnitude of symptom improvement was similar to that of randomized controlled trials. Limitations of the study include a lack of control group, a limitation of most naturalistic studies. These findings indicate that interventions developed in controlled research settings on the efficacy of CBT can be transported to naturalistic, "real world" settings, and that brief CBT delivered in a partial hospital program is effective for many patients with severe depressive symptoms.

Change in defense mechanisms and coping patterns during the course of 2-year-long psychotherapy and psychoanalysis for recurrent depression: a pilot study of a randomized controlled trial

Very little research has been conducted so far to study the potential mechanisms of change in long-term active psychological treatments of recurrent depression. The present pilot randomized controlled trial aimed to determine the feasibility of studying the change process occurring in patients during the course of 2-year-long dynamic psychotherapy, psychoanalysis, and cognitive therapy, as compared with clinical management. In total, eight outpatients presenting with recurrent depression, two patients per treatment arm, were included. All patients were randomly assigned to one of the four treatment conditions. Defense mechanisms and coping patterns were assessed using validated observer-rated methodology based on transcribed, semistructured follow-along independent dynamic interviews. The results indicated that, whereas some patients in the active treatments changed on the symptomatic levels, some others remained unchanged during the course of their 2-year-long treatment. However, with regard to potential mechanisms of change in these patients, changes in defense mechanisms and coping patterns were revealed to be important processes over time in successful therapies and, to a lesser extent, in less successful treatments. No change was found either on outcome or on the process measure for the control condition, that is, clinical management. These results are discussed along with previous data comparing change in defense mechanisms and coping during the course of treatments.

Enhancing information pertaining to client characteristics to facilitate evidence-based practice

OBJECTIVE

Evidence-based practice (EBP) includes utilization of empirically supported treatments, application of clinical expertise, and consideration of client characteristics. The following brief report aims to elucidate barriers in the study and dissemination of research regarding these client characteristics.

DESIGN

Authors examined empirical papers cited on psychologicaltreatments.org (N = 338) and categorized each according to efficacy evidence available pertaining to gender, race/ethnicity, and socioeconomic status (SES).

RESULTS

Gender was most commonly considered (7% of studies), with less than 2% of studies analyzing efficacy in relation to race/ethnicity or SES.

CONCLUSIONS

Available findings are summarized according to disorder. Researchers are encouraged to attend to client variables in efficacy studies and suggestions are offered for training students to include client variables in EBP.

Correlates associated with unipolar depressive disorders in a Latino population

BACKGROUND

This study reports the comparison and associations of demographic, clinical and psychosocial correlates with three unipolar depressive disorders: dysthymia (DYS), major depression (MD) and double depression (DD), and examines to which extent these variables predict the disorders.

SAMPLING AND METHOD

Previously collected data from 563 adults from a community in Puerto Rico were analyzed. One hundred and thirty individuals with DYS, 260 with MD and 173 with DD were compared by demographic variables, psychiatric and physical comorbidity, familial psychopathology, psychosocial stressors, functional impairment, self-reliance, problem recognition and formal use of mental health services. Multinomial regression was used to assess the association of the predictor variables with each of the three disorders.

RESULTS

Similarities outweighed the discrepancies between the disorders. The main differences observed were between MD and DD, while DYS shared common characteristics with both MD and DD. After other variables were controlled, anxiety, functional impairment and problem recognition most strongly predicted a DD diagnosis, while age predicted a DYS diagnosis.

CONCLUSION

MD, DYS and DD are not completely different disorders, but they do differ in key aspects that might be relevant for nosology, research and practice. A dimensional system that incorporates specific categories of disorders would better reflect the different manifestations of unipolar depressive disorders.

Psychotherapy and pharmacotherapy: a contemporary perspective

A contemporary perspective on psychotherapy and pharmacotherapy views both treatments as somatic in nature. Abandoning Cartesian dualism frees the clinician to consider therapeutic options based on the best available evidence rather than falsely dichotomizing approaches as biological or psychological. Evidence-based medicine is a helpful though limited paradigm upon which to base treatment decisions. Instead, clinicians should strive for an evidence-informed approach that is patient centered. This approach is illustrated in relation to depressive illness where moderators of outcome are examined (illness severity, history of trauma, personality disorders, patient preference) that will influence clinical recommendations on combining treatment. Psychotherapy is increasingly proving to be a valuable therapeutic modality across the severity spectrum, a finding at odds with current treatment practices.

Cognitive Behavioural Analysis System of Psychotherapy for Treatment-Resistant Depression: Adaptation to a Group Modality

Studies researching psychotherapeutic interventions for treatment-resistant depression (TRD) are quite new to the field. The Cognitive Behavioural Analysis System of Psychotherapy (CBASP) is the only model developed specifically to treat the chronically depressed patient. While empirical evidence indicates that CBASP is an effective treatment for chronic depression, little is known about its adaptation to a group modality. Treating these patients in a group approach would have the added benefits of being cost-effective and providing in vivo previously avoided interpersonal situations for practising social skills and role-plays. This single arm study asks whether CBASP adapted to a group modality can be effective. All patients received 12 CBASP group therapy sessions with two to four individual preparatory sessions before the group. Our results suggest that CBASP group treatment demonstrated positive effects on patient outcomes. Specifically, patients showed significant decreases in symptoms of depression and the use of emotion-oriented coping, as well as increases in overall social adjustment and interpersonal self-efficacy when compared to pretreatment levels. However, patients did not achieve normative levels in these areas by the end of treatment. These pilot results are encouraging and support further study of the effectiveness of CBASP group treatment with a control group.

The effect of cognitive behavioral group therapy for depression: a meta-analysis 2000-2010

OBJECTIVE

The goals of the meta-analysis were to investigate the overall effectiveness of cognitive behavioral group therapy (CBGT) for depression and relapse prevention in depression from 2000 to 2010, and to investigate how the variables (episode, residual symptoms, group size, control group, group manual, therapist experience, therapy frequency, session length, and take-home assignment) of a CBGT study could affect the effect size.

METHOD

This study collected actual study designs sought of CBGT for depression published from 2000 to 2010. These studies were then cross-referenced using Medical Subject Headings (MeSH) with the following keywords: group therapy, cognitive therapy, cognitive behavioral therapy, cognitive behavioral group therapy, psychotherapy, depression, relapse, and recurrence. The quality of the studies was evaluated using Cochrane Collaboration Guidelines. The effect size of CBGT on depression and relapse prevention in depression used the formula devised by Hedges and Olkin (1985).

RESULTS

The study investigated the results of 32 studies on the effect of CBGT for depression. The CBGT had an immediate (g=-0.40) and continuous effect over 6 months (g=-0.38), but no continuous effect after 6 months (g=-0.06). The CBGT lowered the relapse rate of depression (RD = 0.16). Variables significantly different from each other in terms of immediate effect were: CBGT versus usual care, therapy sessions lasting longer than 1 hour, and take-home assignments. Preintervention severity of depression and patient turnover rate were found to be significantly related to the size of the immediate effect. The relapse rate after 6 months was significantly related only to "participants have no residual symptoms/participants did not mention residual symptoms."

CONCLUSIONS

Researchers and clinicians should take note that CBGT had a moderate effect on the level of depression and a small effect on the relapse rate of depression. The results of this study suggest that the patient should receive a course of therapy at least every 6 months.

Relapse and recurrence prevention in depression: current research and future prospects

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.

Long-term treatment of pediatric depression with psychotherapies

Major depressive disorder in children and adolescents is associated with significant morbidity and mortality, and benefits from intervention. However, studies have focused on acute treatment. Thus, data are limited on long-term treatment (ie, both continuation and maintenance treatment). This article discusses the naturalistic course of depression following acute treatment with psychotherapy and the efficacy of long-term psychotherapy for the prevention of relapse and recurrence in depressed children and adolescents.

Efficacy of the sequential integration of psychotherapy and pharmacotherapy in major depressive disorder: a preliminary meta-analysis

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.

A review of empirically supported psychological therapies for mood disorders in adults

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.

Cognitive behavioral therapy for mood disorders: efficacy, moderators and mediators

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.

Exploring preoperational features in chronic depression

BACKGROUND

The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) by James McCullough is the first psychotherapeutical approach specifically designed for chronic depression. Whereas its efficacy has recently been studied, empirical investigations on the underlying etiopathological hypotheses are missing. McCullough postulates that chronically depressed patients - particularly those with early onset - think preoperationally. This term was coined by J. Piaget and includes egocentrism in the views of self and others and incapacity for authentic interpersonal empathy. In accordance, empirical studies indicate a deficit in theory of mind (ToM) in depressed individuals.

METHODS

Sixteen patients with early onset chronic depression were compared to sixteen matched healthy controls using three measurements: 1) the Movie for the Assessment of Social Cognition (MASC) as a new video-based theory of mind test, 2) self-rated questionnaires on empathy (Interpersonal Reactivity Index (IRI), and a scale assessing individual competence in relationships), and 3) a structured evaluation by the patients' therapists.

RESULTS

The groups did not differ in their theory of mind performance on any aspect assessed by the used test. However, patients rated their empathy in daily life as significantly inferior to healthy controls. In addition, the therapists assigned a considerable amount of preoperational behavior to their patients. No meaningful correlations between these three types of measurements were found.

LIMITATIONS

Small sample size, no structural assessment of possible psychopathology in the control group, control group was not rated by clinicians concerning preoperational behaviors.

CONCLUSIONS

Lack of empathy exists in the daily life of early onset chronically depressed patients according to their own and their therapists' evaluation. However, a video-based test failed to pick up deficits in their theory of mind capacities. Further research is needed to investigate theory of mind deficits using real life interpersonal interactions demanding the patient's personal involvement.

Major depression during interferon-alpha treatment: vulnerability and prevention

Major Depressive Disorder (MDD) during interferons (IFN-α) treatment can occur within a few months of therapy, and shares many homologies with other forms of MDD, Most patients are resilient to the side effect ofinterferon-induced depression (IFN-MDD), but 15% to 40% are vulnerable. Several studies have employed antidepressants to prevent the incidence of an IFN-MDD episode, and the results suggest that prophylactic antidepressants may be specifically useful in those with pre-existing subthreshold depressive symptoms andlor a history of prior MDD episodes. Several other potential markers of vulnerability for IFN-MDD have been implicated in assessments of nondepressed patients before they start IFN-α These include poor sleep quality, premorbid elevations in inflammatory cytokines, genetic polymorphisms in the serotonin system, personality, and social support. The interplay of these factors strongly predicts who is at risk for IFN-MDD, and indicates several potentially modifiable targets for the personalized prevention of IFN-MDD,

Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication

BACKGROUND

In 2001, the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT) partnered to produce evidence-based clinical guidelines for the treatment of depressive disorders. A revision of these guidelines was undertaken by CANMAT in 2008-2009 to reflect advances in the field. This article, one of five in the series, reviews new studies of psychotherapy in the acute and maintenance phase of MDD, including computer-based and telephone-delivered psychotherapy.

METHODS

The CANMAT guidelines are based on a question-answer format to enhance accessibility to clinicians. Evidence-based responses are based on updated systematic reviews of the literature and recommendations are graded according to the Level of Evidence, using pre-defined criteria. Lines of Treatment are identified based on criteria that included evidence and expert clinical support.

RESULTS

Cognitive-Behavioural Therapy (CBT) and Interpersonal Therapy (IPT) continue to have the most evidence for efficacy, both in acute and maintenance phases of MDD, and have been studied in combination with antidepressants. CBT is well studied in conjunction with computer-delivered methods and bibliotherapy. Behavioural Activation and Cognitive-Behavioural Analysis System of Psychotherapy have significant evidence, but need replication. Newer psychotherapies including Acceptance and Commitment Therapy, Motivational Interviewing, and Mindfulness-Based Cognitive Therapy do not yet have significant evidence as acute treatments; nor does psychodynamic therapy.

LIMITATIONS

Although many forms of psychotherapy have been studied, relatively few types have been evaluated for MDD in randomized controlled trials. Evidence about the combination of different types of psychotherapy and antidepressant medication is also limited despite widespread use of these therapies concomitantly.

CONCLUSIONS

CBT and IPT are the only first-line treatment recommendations for acute MDD and remain highly recommended for maintenance. Both computer-based and telephone-delivered psychotherapy--primarily studied with CBT and IPT--are useful second-line recommendations. Where feasible, combined antidepressant and CBT or IPT are recommended as first-line treatments for acute MDD.

[Affective disorders. The significance of psychotherapeutic approaches]

The use of psychotherapeutic strategies is essential in the treatment of affective disorders. Psychotherapy proved to be at least equivalent to antidepressant medication in the treatment of mild to moderate depression. In severe cases, the combination of both treatments is considered by guidelines to be the standard treatment. Psychotherapeutic approaches show a longer latency than antidepressants; however, the effects are longer lasting. Regarding the effectiveness of pharmacotherapy sobering results have been published recently. Therefore, the further development of psychotherapy deserves special attention. Cognitive behavioral therapy and interpersonal therapy provide the highest evidence. The empirical basis for psychodynamic psychotherapies is still limited. In the treatment of chronic depression a new approach--cognitive behavioral analysis system of psychotherapy--is gaining importance. There is a trend towards an increasing specification of psychotherapy for distinct subgroups of depressed patients. Challenges for the future include increasing treatment efficacy, investigating mechanisms of efficacy and predictors for a differential indication, and making effective approaches generally available to all patients.

The Use and Nature of Present-Focused Interventions in Cognitive and Behavioral Therapies for Depression

To improve cognitive and behavioral therapies (CBT) for depression, several approaches recommend an increased focus on the occurrence of problems as they occur in the therapeutic relationship or in relation to the live therapy process, referred to as present-focused. A lingering question has been the degree to which CBT therapists already engage in present-focused work. This study utilized sessions from recent trials of CBT for depression and, in Phase I, raters identified present-focused interventions on a turn-by-turn basis. Phase II raters used a qualitative analysis to determine categories of present-focused interventions. Results indicated that therapists rarely focused on the therapeutic relationship; when they did it was often transient and lacking in the elaborations suggested by newer approaches. Therapists more often performed therapy process and emotion focused interventions, but these also tended to lack elaboration.

Clinical practice recommendations for depression

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Chronic depression: update on classification and treatment

A significant proportion of patients with depressive disorders suffer from chronic conditions. The DSM-IV recognizes several forms of chronic depression. Chronic depressions differ from nonchronic major depressive disorder (MDD) on many clinical, psychosocial, and familial variables. However, less support exists for current distinctions between the various forms of chronic depression. Antidepressant medications and at least some forms of psychotherapy are efficacious in treating chronic depression, and the combination of pharmacotherapy and psychotherapy appears to be superior to either monotherapy alone. Still, chronic depression is often inadequately treated, and many patients fail to respond or continue to experience residual symptoms after treatment. An important direction for future research is to elucidate the multiple pathways to chronic depression and to tailor treatments to specific etiopathogenetic subgroups.

Treatment of chronically depressed patients: a multisite randomized controlled trial testing the effectiveness of 'Cognitive Behavioral Analysis System of Psychotherapy' (CBASP) for chronic depressions versus usual secondary care

BACKGROUND

'Cognitive Behavioral Analysis System of Psychotherapy' (CBASP) is a form of psychotherapy specifically developed for patients with chronic depression. In a study in the U.S., remarkable favorable effects of CBASP have been demonstrated. However, no other studies have as yet replicated these findings and CBASP has not been tested outside the United States. This protocol describes a randomized controlled trial on the effectiveness of CBASP in the Netherlands.

METHODS/DESIGN

The purpose of the present paper is to report the study protocol of a multisite randomized controlled trial testing the effectiveness of 'Cognitive Behavioral Analysis System of Psychotherapy' (CBASP) for chronic depression in the Netherlands. In this study, CBASP in combination with medication, will be tested versus usual secondary care in combination with medication. The aim is to recruit 160 patients from three mental health care organizations. Depressive symptoms will be assessed at baseline, after 8 weeks, 16 weeks, 32 weeks and 52 weeks, using the 28-item Inventory for Depressive Symptomatology (IDS). Effect modification by co morbid anxiety, alcohol consumption, general and social functioning and working alliance will be tested. GEE analyses of covariance, controlling for baseline value and center will be used to estimate the overall treatment effectiveness (difference in IDS score) at post-treatment and follow up. The primary analysis will be by 'intention to treat' using double sided tests. An economic analysis will compare the two groups in terms of mean costs and cost-effectiveness from a societal perspective.

DISCUSSION

The study will provide an answer to the question whether the favorable effects of CBASP can be replicated outside the US.

TRIAL REGISTRATION

The Dutch Cochrane Center, NTR1090.