The treatment of depression with group behavioural-cognitive therapy and imipramine

A network meta-analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression

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.

A measure of cognitions specific to seasonal depression: Development and validation of the Seasonal Beliefs Questionnaire

We introduce the Seasonal Beliefs Questionnaire (SBQ), a self-report inventory of maladaptive thoughts about the seasons, light availability, and weather conditions, proposed to constitute a unique cognitive vulnerability to winter seasonal affective disorder (SAD; Rohan, Roecklein, & Haaga, 2009). Potential items were derived from a qualitative analysis of self-reported thoughts during SAD-tailored cognitive-behavioral therapy (CBT-SAD) and subsequently refined based on qualitative feedback from 48 SAD patients. In the psychometric study (N = 536 college students), exploratory and confirmatory factor analyses pruned the items to a 26-item scale with a 5-factor solution, demonstrating good internal consistency, convergent and divergent validity, and 2-week test-retest reliability. In a known groups comparison, the SBQ discriminated SAD patients (n = 86) from both nonseasonal major depressive disorder (MDD) patients (n = 30) and healthy controls (n = 110), whereas a generic measure of depressogenic cognitive vulnerability (the Dysfunctional Attitudes Scale [DAS]) discriminated MDD patients from the other groups. In a randomized clinical trial comparing CBT-SAD with light therapy (N = 177), SBQ scores improved at twice the rate in CBT-SAD than in light therapy. Greater change in SBQ scores during CBT-SAD, but not during light therapy, was associated with a lower risk of depression recurrence 2 winters later. In contrast, DAS scores improved comparably during CBT-SAD and light therapy, and DAS change was unrelated to recurrence following either treatment. These results support using the SBQ as a brief assessment tool for a SAD-specific cognitive vulnerability and as a treatment target in CBT-SAD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Dysfunctional cognitions of depressive inpatients and their relationship with treatment outcome

BACKGROUND

Dysfunctional cognitions can contribute to depression and its maintenance. They may be related to a higher relapse rate and a longer duration of the depressive episode. The relevance of dysfunctional cognitions for acute inpatient treatment of unipolar depression is examined in this study and its variability by cognitive behavioural therapy (CBT).

METHODS

222 patients suffering from Major Depressive Disorder (MDD) were evaluated during their inpatient treatment by assessing admission and discharge depression scores and their relationship to dysfunctional cognitions, using the Dysfunctional Attitude Scale (DAS). The relationship between dysfunctional cognitions and treatment outcome was examined. Primary outcome measures were the Hamilton-Rating-Scale (HRSD) and the Beck Depression Inventory (BDI).

RESULTS

Higher age, depression severity at admission, comorbid personality disorders and recurrent depressive disorders are related with higher DAS-scores at admission. DAS-Scores declined during treatment but to a lower extend than depressive symptom scales (effect size dDAS-G t1-t2 = .31; dHRSD t1-t2 = 2.88; dBDI t1-t2 = 1.38). Higher DAS-scores at admission correlated negatively with the improvement of depressive symptoms during treatment (HRSD: r = -.62; p < .01; BDI: r = -.54; p < .01) and remission rates (HRSD: r = -.65; p < .01; BDI: r = -.48; p < .01). CBT did not additionally reduce DAS-scores compared to pharmacotherapy only.

CONCLUSION

Dysfunctional cognitions are relatively stable compared to other depressive symptoms and are associated with poorer treatment outcome even in combined treatment of antidepressant medication and CBT during inpatient treatment. Changes of dysfunctional cognitions seem to be a long-term treatment goal, especially because of their association with comorbid personality disorders and recurrent depressive disorders.

Cognitive Change across Cognitive-Behavioral and Light Therapy Treatments for Seasonal Affective Disorder: What Accounts for Clinical Status the Next Winter?

Efficacious treatments for seasonal affective disorder include light therapy and a seasonal affective disorder-tailored form of cognitive-behavioral therapy. Using data from a parent clinical trial, these secondary analyses examined the relationship between cognitive change over treatment with cognitive-behavioral therapy, light therapy, or combination treatment and mood outcomes the next winter. Sixty-nine participants were randomly assigned to 6-weeks of cognitive-behavioral therapy, light therapy, or combination treatment. Cognitive constructs (i.e., dysfunctional attitudes, negative automatic thoughts, and rumination) were assessed at pre- and post-treatment. Dysfunctional attitudes, negative automatic thoughts, and rumination improved over acute treatment, regardless of modality; however, in participants randomized to solo cognitive-behavioral therapy, a greater degree of improvement in dysfunctional attitudes and automatic thoughts was uniquely associated with less severe depressive symptoms the next winter. Change in maladaptive thoughts during acute treatment appears mechanistic of solo cognitive-behavioral therapy's enduring effects the next winter, but is simply a consequence of diminished depression in light therapy and combination treatment.

Psychotherapy versus the combination of psychotherapy and pharmacotherapy in the treatment of depression: a meta-analysis

BACKGROUND

A large number of studies have shown that psychological treatments have significant effects on depression. Although several studies have examined the relative effects of psychological and combined treatments, this has not been studied satisfactorily in recent statistical meta-analyses.

METHOD

We conducted a meta-analysis of randomized studies in which a psychological treatment was compared to a combined treatment consisting of the same psychological treatment with a pharmacological therapy. For each of these studies we calculated the effect size indicating the difference between the psychological and the combined treatment.

RESULTS

All inclusion criteria were met by 18 studies, with a total of 1,838 subjects. The mean effect size indicating the difference between psychological and combined treatment was 0.35 (95% CI: 0.24 approximately 0.45; P<0.001), with low heterogeneity. Subgroup analyses indicated that the difference between psychological and combined treatments was significantly smaller in studies in which cognitive behavior therapy was examined. We also found a trend (P<0.1) indicating that the difference between psychological and combined treatment was somewhat larger in studies aimed at specific populations (older adults, chronic depression, HIV patients) than in studies with adults, and in studies in which Trycyclic antidepressants or SSRIs were examined, compared to studies in which a medication protocol or another antidepressant was used. At follow-up, no difference between psychological and combined treatments was found.

CONCLUSION

We conclude that combined treatment is more effective than psychological treatment alone. However, it is not clear whether this difference is relevant from a clinical perspective.

The effectiveness of group cognitive behaviour therapy for unipolar depressive disorders

This paper evaluates the effectiveness of group cognitive behaviour therapy (GCBT) as an intervention for unipolar depressive disorders. PsychINFO and PubMed databases were selected to generate the 34 papers used for this review. Our results showed that effect sizes for GCBT over the control conditions range from small (0.1) to large (2.87) with the mean effect size of 1.10. The pre-post treatment effect sizes for GCBT range from 0.30 to 3.72 with a mean of 1.30. Convergent evidence was demonstrated across different outcome measures of GCBT. Our findings indicated that GCBT yielded outcomes better than no-treatment controls and was comparable with other treatments (including both bona fide and non-bona fide comparison treatments). It was concluded that GCBT was effective for the treatment of Unipolar depression and thus can be used with confidence. There is now an urgent need to develop and evaluate a coherent GCBT theory, in particular the roles of group processes in GCBT, before further major advancement in this area can be made.

The evaluation of cognitive-behavioral group therapy on patient depression and self-esteem

We evaluated the impact of cognitive-behavioral group therapy on the depression and self-esteem of clinically depressed patients. This longitudinal study involved 26 experimental group patients who received 12 weeks of cognitive-behavioral group therapy and 25 comparison subjects. Two weeks before the study, immediately upon therapy completion, and 1 month later, all the participants underwent pretest, posttest, and follow-up, respectively. The experimental group patients experienced greater cognitive improvements (i.e., depression relief, self-esteem increase) as compared with the comparison group subjects. One month after therapy completion, the depressive symptoms and self-esteem of the experimental group patients remained slightly but significantly better than those of the comparison group subjects.

Cognitive behavioural therapy for depression, panic disorder and generalized anxiety disorder: a meta-regression of factors that may predict outcome

OBJECTIVE

To determine which factors impact on the efficacy of cognitive behavioural therapy (CBT) for depression and anxiety. Factors considered include those related to clinical practice: disorder, treatment type, duration and intensity of treatment, mode of therapy, type and training of therapist and severity of patients. Factors related to the conduct of the trial were also considered, including: year of study, country of study, type of control group, language, number of patients and percentage of dropouts from the trial.

METHOD

We used the technique of meta-analysis to determine an overall effect size (standardized mean difference calculated using Hedges' g) and meta-regression to determine the factors that impact on this effect size. We included randomized controlled trials with a wait list, pill placebo or attention/psychological placebo control group. Study participants had to be 18 years or older and all have diagnosed depression, panic disorder (with or without agoraphobia) or generalized anxiety disorder (GAD). Outcomes of interest included symptom, functioning and health-related quality of life measures, reported as continuous variables at post-treatment.

RESULTS

Cognitive behavioural therapy for depression, panic disorder and GAD had an effect size of 0.68 (95% CI=0.51-0.84, n=33 studies, 52 comparisons). The heterogeneity in the effect sizes was fully explained by treatment, duration of therapy, inclusion of severe patients in the trial, year of study, country of study, control group, language and number of dropouts from the control group. Disorder was not a significant predictor of the effect size.

CONCLUSIONS

Cognitive behavioural therapy is significantly less effective for severe patients and trials that compared CBT to a wait-list control group found significantly larger effect sizes than those comparing CBT to an attention placebo, but not to a pill placebo. Further research is needed to determine whether CBT is effective when provided by others than psychologists and whether it is effective for non-English-speaking patient groups.

A comparative evaluation of community treatments for post-partum depression: implications for treatment and management practices

OBJECTIVE

To compare existing community treatments for post-partum depression (PPD), treatment efficacy was evaluated for 146 women seeking treatment for PPD in the local community.

METHODS

Self-report questionnaires were designed to assess clinical depression and anxiety (psychological and physiological), risk factors, treatment satisfaction and the impact of social supports.

RESULTS

Comparison of treated subjects with those on a wait-list demonstrated that depression and the psychological component of anxiety decreased significantly after treatment. Psychological and pharmacological interventions produced similar clinical benefit in the treatment of psychological symptoms, and receiving both treatments in combination was of no added clinical benefit in the immediate or longer term. Individual treatment was associated with more rapid treatment gains initially than group treatment. However, the benefits of group treatment emerged during the 6 months following treatment, leading both interventions to be equally effective in the longer term. Cognitive behavioural therapy was not superior to the combination of non-specific counselling or behavioural strategies, either immediately following treatment or 6 months later.

CONCLUSIONS

Clinical efficacy together with other clinical and financial benefits strongly advocate the application of psychological treatment for PPD. Clear parallels between PPD and general depression support the application of knowledge about general depression to extend understanding of PPD and refine clinical management practices.

The strengths and weaknesses of cognitive behavioural approaches to treating depression and their potential for wider utilization by mental health nurses

Depression is widely acknowledged to be the major factor implicated with suicide, an enormous financial cost on the economies of western countries and a source of intense despair for millions of people around the world. A steady stream of articles are published both in popular, generic and specialist nursing journals that illustrate the potential of cognitive behavioural therapies in the treatment of depression. Should these therapies be restricted for use by registered therapists or do the techniques have a wider application? The marketing of these approaches for use by nurses prompted a review of the purported strengths and weaknesses of these approaches in comparison with other possible alternatives. Many mental health nurses in community settings already use cognitive behavioural approaches with clients. Here it will be argued that several of the recognized strengths of cognitive behavioural approaches lend themselves to incorporation in nurse-patient interactions in varied in-patient settings by nurses who spend protracted periods of time with depressed patients but lack formal therapist qualifications and do not consider themselves counsellors.

A meta-analysis of the effects of cognitive therapy in depressed patients

BACKGROUND

Cognitive therapy (CT) has been studied in 78 controlled clinical trials from 1977 to 1996.

METHOD

The meta-analysis used Hedges and Olkin d+ and included 48 high-quality controlled trials. The 2765 patients presented non-psychotic and non-bipolar major depression, or dysthymia of mild to moderate severity.

RESULTS

At post-test CT appeared significantly better than waiting-list, antidepressants (P < 0.0001) and a group of miscellaneous therapies (P < 0.01). But, CT was equal to behaviour therapy. As between-trial homogeneity was not met, the comparisons of CT with waiting-list or placebo, and other therapies should be taken cautiously. In contrast, between-trial homogeneity was high for the comparisons of CT with behaviour therapy and antidepressants. A review of eight follow-up studies comparing CT with antidepressants suggested that CT may prevent relapses in the long-term, while relapse rate is high with antidepressants in naturalistic studies.

CONCLUSION

CT is effective in patients with mild or moderate depression.