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Serbanescu I, Backenstrass M, Drost S, Weber B, Walter H, Klein JP, Zobel I, Hautzinger M, Meister R, Härter M, Schramm E, Schoepf D. Impact of Baseline Characteristics on the Effectiveness of Disorder-Specific Cognitive Behavioral Analysis System of Psychotherapy (CBASP) and Supportive Psychotherapy in Outpatient Treatment for Persistent Depressive Disorder. Front Psychiatry 2020; 11:607300. [PMID: 33408656 PMCID: PMC7779472 DOI: 10.3389/fpsyt.2020.607300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/11/2020] [Indexed: 11/13/2022] Open
Abstract
Importance: In the treatment of persistent depressive disorder (PDD), disorder-specific Cognitive Behavioral Analysis System of Psychotherapy (CBASP) has been shown to be superior to Supportive Psychotherapy (SP) in outpatients. It remains to clear which subgroups of patients benefit equally and differentially from both psychotherapies. Objective: To identify those patient-level baseline characteristics that predict a comparable treatment effectiveness of CBASP and SP and those that moderate the differential effectiveness of CBASP compared to SP. Design, setting and participants: In this analysis of a 48-week multicenter randomized clinical trial comparing CBASP to SP in adult antidepressant-free outpatients with early-onset PDD, we evaluated baseline variables from the following domains as potential predictors and moderators of treatment effectiveness: socio-demography, clinical status, psychosocial and global functioning, life quality, interpersonal problems, childhood trauma, treatment history, preference for psychotherapy, and treatment expectancy. Interventions: A 48-week treatment program with 32 sessions of either CBASP or SP. Main outcomes and measures: Depression severity measured by the 24-item Hamilton Rating Scale for Depression (HRSD-24) at week 48. Results: From N = 268 randomized outpatients, N = 209 completed the 48-week treatment program. CBASP completers had significantly lower post-treatment HRSD-24 scores than SP completers (meanCBASP=13.96, sdCBASP= 9.56; meanSP= 16.69, sdSP= 9.87; p = 0.04). A poor response to both therapies was predicted by higher baseline levels of clinician-rated depression, elevated suicidality, comorbid anxiety, lower social functioning, higher social inhibition, moderate-to-severe early emotional or sexual abuse, no preference for psychotherapy, and the history of at least one previous inpatient treatment. Moderator analyses revealed that patients with higher baseline levels of self-rated depression, comorbidity of at least one Axis-I disorder, self-reported moderate-to-severe early emotional or physical neglect, or at least one previous antidepressant treatment, had a significantly lower post-treatment depression severity with CBASP compared to SP (all p < 0.05). Conclusions and relevance: A complex multifactorial interaction between severe symptoms of depression, suicidality, and traumatic childhood experiences characterized by abuse, social inhibition, and anxiety may represent the basis of non-response to psychotherapy in patients with early onset PDD. Specific psychotherapy with CBASP might, however, be more effective and recommendable for a variety of particularly burdened patients compared to SP.
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Affiliation(s)
- Ilinca Serbanescu
- Department of Clinical Psychology and Psychotherapy, University of Heidelberg, Heidelberg, Germany
| | - Matthias Backenstrass
- Department of Clinical Psychology and Psychotherapy, University of Heidelberg, Heidelberg, Germany
- Institute of Clinical Psychology, Hospital Stuttgart, Stuttgart, Germany
| | - Sarah Drost
- Department of Psychiatry and Psychotherapy, Cognitive Behavioral Analysis System of Psychotherapy Center of Competence, University of Bonn, Bonn, Germany
| | - Bernd Weber
- Institute of Experimental Epileptology and Cognition Research, University of Bonn, Bonn, Germany
- Center for Economics and Neuroscience, University of Bonn, Bonn, Germany
| | - Henrik Walter
- Department of Psychiatry and Psychotherapy, Charité-University Medicine Berlin, Berlin, Germany
| | - Jan Philipp Klein
- Department of Psychiatry and Psychotherapy, Lübeck University, Lübeck, Germany
| | - Ingo Zobel
- Psychology School at the Fresenius University of Applied Sciences Berlin, Berlin, Germany
| | - Martin Hautzinger
- Department of Psychology, Clinical Psychology and Psychotherapy, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Ramona Meister
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg-Eppendorf, Germany
| | - Martin Härter
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg-Eppendorf, Germany
| | - Elisabeth Schramm
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Dieter Schoepf
- Department of Psychiatry and Psychotherapy, Cognitive Behavioral Analysis System of Psychotherapy Center of Competence, University of Bonn, Bonn, Germany
- Department of Psychiatry and Psychotherapy, Vitos Weil-Lahn, Weilmünster, Germany
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Furukawa TA, Karyotaki E, Suganuma A, Pompoli A, Ostinelli EG, Cipriani A, Cuijpers P, Efthimiou O. Dismantling, personalising and optimising internet cognitive-behavioural therapy for depression: a study protocol for individual participant data component network meta-analysis. BMJ Open 2019; 8:e026137. [PMID: 30798295 PMCID: PMC6278798 DOI: 10.1136/bmjopen-2018-026137] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Psychotherapy is a complex intervention, consisting of various components and being implemented flexibly in consideration of individual patient's characteristics. It is then of utmost importance to know which of the various components or combinations thereof are more efficacious, what their specific effect sizes are and which types of patients may benefit more from different components or their combinations. METHODS AND ANALYSIS Internet-delivered cognitive-behavioural therapy (iCBT) offers a unique opportunity to systematically review and quantitatively disentangle the efficacy of various components because, unlike face-to-face cognitive-behavioural therapy, it allows identification of constituent components that are actually delivered to patients. We will systematically identify all randomised controlled trials that compared any form of iCBT against another form or a control intervention in the acute phase treatment of adult depression. We will apply component network meta-analysis (cNMA) to dismantle efficacy of individual components. We will use individual participant data in the cNMA to identify participant-level prognostic factors and effect modifiers for different components. ETHICS AND DISSEMINATION The investigators of the primary trials will have obtained ethical approval for the data used in the present study and for sharing the data, if this was necessary, according to local requirements and was not covered from the initial ethic assessment. Results from this study will be published in peer-reviewed journals and presented at relevant conferences. PROSPERO REGISTRATION NUMBER CRD42018104683.
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Affiliation(s)
- Toshi A Furukawa
- Departments of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/ School of Public Health, Kyoto, Japan
| | - Eirini Karyotaki
- Department of Clinical, Neuro-, and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Aya Suganuma
- Departments of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/ School of Public Health, Kyoto, Japan
- Amsterdam Public Health research institute, Faculty of Behavioural and Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands
| | | | | | - Andrea Cipriani
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Pim Cuijpers
- Department of Clinical, Neuro-, and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health research institute, Faculty of Behavioural and Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands
| | - Orestis Efthimiou
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
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Furukawa TA, Schramm E, Weitz ES, Salanti G, Efthimiou O, Michalak J, Watanabe N, Cipriani A, Keller MB, Kocsis JH, Klein DN, Cuijpers P. Cognitive-Behavioural Analysis System of Psychotherapy (CBASP), a drug, or their combination: differential therapeutics for persistent depressive disorder: a study protocol of an individual participant data network meta-analysis. BMJ Open 2016; 6:e011769. [PMID: 27147393 PMCID: PMC4861112 DOI: 10.1136/bmjopen-2016-011769] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Despite important advances in psychological and pharmacological treatments of persistent depressive disorders in the past decades, their responses remain typically slow and poor, and differential responses among different modalities of treatments or their combinations are not well understood. Cognitive-Behavioural Analysis System of Psychotherapy (CBASP) is the only psychotherapy that has been specifically designed for chronic depression and has been examined in an increasing number of trials against medications, alone or in combination. When several treatment alternatives are available for a certain condition, network meta-analysis (NMA) provides a powerful tool to examine their relative efficacy by combining all direct and indirect comparisons. Individual participant data (IPD) meta-analysis enables exploration of impacts of individual characteristics that lead to a differentiated approach matching treatments to specific subgroups of patients. METHODS AND ANALYSIS We will search for all randomised controlled trials that compared CBASP, pharmacotherapy or their combination, in the treatment of patients with persistent depressive disorder, in Cochrane CENTRAL, PUBMED, SCOPUS and PsycINFO, supplemented by personal contacts. Individual participant data will be sought from the principal investigators of all the identified trials. Our primary outcomes are depression severity as measured on a continuous observer-rated scale for depression, and dropouts for any reason as a proxy measure of overall treatment acceptability. We will conduct a one-step IPD-NMA to compare CBASP, medications and their combinations, and also carry out a meta-regression to identify their prognostic factors and effect moderators. The model will be fitted in OpenBUGS, using vague priors for all location parameters. For the heterogeneity we will use a half-normal prior on the SD. ETHICS AND DISSEMINATION This study requires no ethical approval. We will publish the findings in a peer-reviewed journal. The study results will contribute to more finely differentiated therapeutics for patients suffering from this chronically disabling disorder. TRIAL REGISTRATION NUMBER CRD42016035886.
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Affiliation(s)
- Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Elisabeth Schramm
- Department of Psychiatry and Psychotherapy, University Medical Center Freiburg, Freiburg, Germany
| | - Erica S Weitz
- Department of Clinical, Neuro and Developmental Psychology, EMGO Institute for Health and Care Research, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Georgia Salanti
- Institute of Social and Preventive Medicine (ISPM) & Bern Institute of Primary Care (BIHAM), University of Bern, Bern, Switzerland
| | - Orestis Efthimiou
- Institute of Social and Preventive Medicine (ISPM) & Bern Institute of Primary Care (BIHAM), University of Bern, Bern, Switzerland
| | - Johannes Michalak
- Department of Psychology and Psychotherapy, Witten/Herdecke University, Witten, Germany
| | - Norio Watanabe
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | | | - Martin B Keller
- Department of Psychiatry and Human Behavior, Brown University, Providence, Rhode Island, USA
| | - James H Kocsis
- Department of Psychiatry, Weill Cornell Medical College, New York, New York, USA
| | - Daniel N Klein
- Department of Psychology, Stony Brook University, Stony Brook, New York, USA
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, EMGO Institute for Health and Care Research, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Dunlop BW. Evidence-Based Applications of Combination Psychotherapy and Pharmacotherapy for Depression. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2016; 14:156-173. [PMID: 31975799 PMCID: PMC6519650 DOI: 10.1176/appi.focus.20150042] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Boadie W Dunlop
- Dr. Dunlop is with the Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia (e-mail: )
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Goelz PM, Audrain-McGovern JE, Hitsman B, Leone FT, Veluz-Wilkins A, Jepson C, Wileyto EP, D'Avanzo PA, Rivera JG, Schnoll RA. The association between changes in alternative reinforcers and short-term smoking cessation. Drug Alcohol Depend 2014; 138:67-74. [PMID: 24598122 PMCID: PMC4030632 DOI: 10.1016/j.drugalcdep.2014.02.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 01/29/2014] [Accepted: 02/01/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND While more than 50% of smokers make a serious quit attempt each year, less than 10% quit permanently. Evidence from studies of adolescent smoking and other substances of abuse suggest that alternative reinforcers, a construct of Behavioral Economic Theory, may contribute to the likelihood of smoking cessation in adults. This study examined the behavioral economics of smoking cessation within a smoking cessation clinical trial and evaluated how depressive symptoms and behavioral economic variables are associated with smoking cessation. METHODS A sample of 469 smokers, enrolled in an effectiveness trial that provided counseling and 8 weeks of 21 mg nicotine patches, was analyzed. Alternative reinforcers (substitute and complementary reinforcers) and depressive symptoms were examined in relation to 7-day point prevalence abstinence, verified with breath carbon monoxide, 8 weeks after the quit date. RESULTS Controlling for covariates associated with cessation (nicotine dependence, age of smoking initiation, patch adherence), participants who were abstinent at week 8 showed significantly higher substitute reinforcers at all time-points, compared to those who were smoking (p's<.05). Participants who were abstinent at week 8 showed lower complementary reinforcers and depressive symptoms at all time-points, compared to those who were smoking, but significant differences were confined to week 8 (p's<.01). There was no significant interaction between alternative reinforcers and depressive symptoms across the 8 weeks on week 8 abstinence. CONCLUSIONS These results support continued examination of Behavioral Economic Theory in understanding adult smoking cessation in order to inform future treatments and guidelines.
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Affiliation(s)
- Patricia M Goelz
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Suite 4100, Philadelphia, PA 19104, United States.
| | - Janet E Audrain-McGovern
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Suite 4100, Philadelphia, PA 19104, United States
| | - Brian Hitsman
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, 680 N Lakeshore Drive, Chicago, IL 60611, United States
| | - Frank T Leone
- Pulmonary, Allergy, & Critical Care Division, University of Pennsylvania Presbyterian Medical Center, 51 N. 39th Street, 1st Floor Rear, Philadelphia, PA 19104, United States
| | - Anna Veluz-Wilkins
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, 680 N Lakeshore Drive, Chicago, IL 60611, United States
| | - Christopher Jepson
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Suite 4100, Philadelphia, PA 19104, United States
| | - E Paul Wileyto
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Suite 4100, Philadelphia, PA 19104, United States
| | - Paul A D'Avanzo
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Suite 4100, Philadelphia, PA 19104, United States
| | - Jonathan G Rivera
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Suite 4100, Philadelphia, PA 19104, United States
| | - Robert A Schnoll
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Suite 4100, Philadelphia, PA 19104, United States
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Craighead WE, Dunlop BW. Combination Psychotherapy and Antidepressant Medication Treatment for Depression: For Whom, When, and How. Annu Rev Psychol 2014; 65:267-300. [DOI: 10.1146/annurev.psych.121208.131653] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- W. Edward Craighead
- Department of Psychiatry and Behavioral Sciences and
- Department of Psychology, Emory University, Atlanta, Georgia 30322; ,
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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: 381] [Impact Index Per Article: 34.6] [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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Smits JA, Minhajuddin A, Thase ME, Jarrett RB. Outcomes of acute phase cognitive therapy in outpatients with anxious versus nonanxious depression. PSYCHOTHERAPY AND PSYCHOSOMATICS 2012; 81:153-60. [PMID: 22398963 PMCID: PMC3362240 DOI: 10.1159/000334909] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 11/03/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Compared to nonanxious depressed patients, anxious depressed patients respond less to pharmacotherapy, prompting consideration of alternate treatments. Based on the transdiagnostic principles of cognitive therapy (CT), we predicted that anxious depressed patients would respond as well to CT as nonanxious depressed patients. METHOD Adults (n = 523) with recurrent major depressive disorder received 12-14 weeks of CT as part of the Continuation Phase Cognitive Therapy Relapse Prevention Trial. Anxious depressed patients (n = 264; 50.4%) were compared to nonanxious depressed patients (n = 259; 49.6%) on demographic variables, initial severity, attrition, and rates and patterns of response and remission. RESULTS Anxious depressed patients presented with greater illness severity and had significantly lower response (55.3 vs. 68.3%) and remission rates (26.9 vs. 40.2%) based on clinician-administered measures. By contrast, smaller between-group differences for attrition, and for response (59.1 vs. 64.9%) and remission (41.7 vs. 48.7%) rates on self-report measures were not significant. Further, anxious depressed patients had greater speed of improvement on self-reported anxiety symptom severity and clinician-rated depressive and anxiety symptom severity measures. CONCLUSION Consistent with prior reports, anxious depressed patients presented with greater severity and, following CT, had lower response and remission rates on clinician-administered scales. However, anxious depressed patients improved more rapidly and response and remission rates on self-report measures were not significantly different from nonanxious depressed patients. Our findings suggest that anxious depressed patients may simply need additional time or more CT sessions to reach outcomes fully comparable to those of less anxious patients.
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Affiliation(s)
- Jasper A.J. Smits
- Department of Psychology, Southern Methodist University, Dallas, Tex., USA,*Jasper A.J. Smits, PhD, Department of Psychology, Southern Methodist University, Dedman College, PO Box 750442, Dallas, TX 75275 (USA), Tel. +1 214 768 4125, E-Mail
| | - Abu Minhajuddin
- Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, Dallas, Tex., USA
| | - Michael E. Thase
- University of Pennsylvania School of Medicine, Philadelphia, Pa., USA,Philadelphia Veterans Affairs Medical Center, Philadelphia, Pa., USA,University of Pittsburgh Medical Center, Pittsburg, Pa., USA
| | - Robin B. Jarrett
- Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, Dallas, Tex., USA
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Abstract
CBT is a valuable treatment for mild, moderate, and severe forms of major depression. It is equally effective and more durable than medication alone, and the combination of medication and CBT may increase the response rate and extend durability when CBT is employed after pharmacotherapy is successful. Therapist competence has been shown to influence outcomes in CBT for depression. Practitioners who wish to learn more about CBT may access a wide variety of educational materials: basic texts, course offerings at major scientific meetings, and local and national training centers are available. The Academy of Cognitive Therapy website (www.academyofct.org) provides detailed information about obtaining training and certification in CBT.
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Affiliation(s)
- Donna M Sudak
- Department of Psychiatry, Drexel University College of Medicine, PO Box 45358, Philadelphia, PA 19124, USA.
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Stulz N, Crits-Christoph P. Distinguishing anxiety and depression in self-report: purification of the beck anxiety inventory and beck depression inventory-II. J Clin Psychol 2010; 66:927-40. [DOI: 10.1002/jclp.20701] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Smits JAJ, Minhajuddin A, Jarrett RB. Cognitive therapy for depressed adults with comorbid social phobia. J Affect Disord 2009; 114:271-8. [PMID: 18804285 PMCID: PMC2677376 DOI: 10.1016/j.jad.2008.08.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Revised: 07/16/2008] [Accepted: 08/05/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Evidence suggests that comorbid depression influences the outcome of cognitive-behavioral treatment for patients presenting with social phobia. Little is known, however, about the influence of comorbid social phobia on the response to cognitive therapy (CT) for depression among adults presenting with recurrent major depressive disorder (MDD). These analyses seek to clarify this relationship. METHODS Patients (N=156) with recurrent DSM-IV MDD entered CT (20% also met DSM-IV criteria for social phobia). Every week during the course of CT, clinicians assessed depressive symptoms and patients completed self-report instruments measuring severity of depression and anxiety. RESULTS At presentation, outpatients with comorbid social phobia reported greater levels of depressive symptoms and clinicians rated their impairment as more severe, compared to their counterparts without social phobia. Patients with or without comorbid social phobia did not differ significantly in (1) attrition rates; (2) response or sustained remission rates; (3) time to response or sustained remission; or (4) rate of improvement in symptoms of depression or anxiety. LIMITATIONS The lack of domain-specific measures limits inference with respect to the improvements in social anxiety that occur with CT of depression. CONCLUSIONS These findings introduce the hypothesis that CT for depression may be flexible enough to treat the depressive symptoms of patients presenting with MDD who also suffer from social phobia.
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Affiliation(s)
| | - Abu Minhajuddin
- The University of Texas Southwestern Medical Center at Dallas
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Friedman ES, Thase ME, Wisniewski SR, Trivedi MH, Biggs MM, Fava M, Warden D, Niederehe G, Luther JF, Rush AJ. Cognitive Therapy Augmentation versus CT Switch Treatment: A STAR*D Report. Int J Cogn Ther 2009. [DOI: 10.1521/ijct.2009.2.1.66] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Cognitive and Behavioral Mediators of Combined Pharmacotherapy and Psychotherapy of Chronic Depression. COGNITIVE THERAPY AND RESEARCH 2007. [DOI: 10.1007/s10608-006-9092-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Millan MJ. Multi-target strategies for the improved treatment of depressive states: Conceptual foundations and neuronal substrates, drug discovery and therapeutic application. Pharmacol Ther 2006; 110:135-370. [PMID: 16522330 DOI: 10.1016/j.pharmthera.2005.11.006] [Citation(s) in RCA: 419] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2005] [Accepted: 11/28/2005] [Indexed: 12/20/2022]
Abstract
Major depression is a debilitating and recurrent disorder with a substantial lifetime risk and a high social cost. Depressed patients generally display co-morbid symptoms, and depression frequently accompanies other serious disorders. Currently available drugs display limited efficacy and a pronounced delay to onset of action, and all provoke distressing side effects. Cloning of the human genome has fuelled expectations that symptomatic treatment may soon become more rapid and effective, and that depressive states may ultimately be "prevented" or "cured". In pursuing these objectives, in particular for genome-derived, non-monoaminergic targets, "specificity" of drug actions is often emphasized. That is, priority is afforded to agents that interact exclusively with a single site hypothesized as critically involved in the pathogenesis and/or control of depression. Certain highly selective drugs may prove effective, and they remain indispensable in the experimental (and clinical) evaluation of the significance of novel mechanisms. However, by analogy to other multifactorial disorders, "multi-target" agents may be better adapted to the improved treatment of depressive states. Support for this contention is garnered from a broad palette of observations, ranging from mechanisms of action of adjunctive drug combinations and electroconvulsive therapy to "network theory" analysis of the etiology and management of depressive states. The review also outlines opportunities to be exploited, and challenges to be addressed, in the discovery and characterization of drugs recognizing multiple targets. Finally, a diversity of multi-target strategies is proposed for the more efficacious and rapid control of core and co-morbid symptoms of depression, together with improved tolerance relative to currently available agents.
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Affiliation(s)
- Mark J Millan
- Institut de Recherches Servier, Centre de Recherches de Croissy, Psychopharmacology Department, 125, Chemin de Ronde, 78290-Croissy/Seine, France.
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Abstract
BACKGROUND The Royal Australian and New Zealand College of Psychiatrists (RANZCP) is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Ministry of Health. METHOD The CPG team reviewed the treatment outcome literature, consulted with practitioners and patients and conducted meta-analyses of outcome research. TREATMENT RECOMMENDATIONS Establish an effective therapeutic relationship; provide the patient with information about the condition, the rationale for treatment, the likelihood of a positive response and the expected timeframe; consider the patient's strengths, life stresses and supports. Treatment choice depends on the clinician's skills and the patient's circumstances and preferences, and should be guided but not determined by these guidelines. In moderately severe depression, all recognized antidepressants, cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT) are equally effective; clinicians should consider treatment burdens as well as benefits, including side-effects and toxicity. In severe depression, antidepressant treatment should precede psychological therapy. For depression with psychosis, electroconvulsive therapy (ECT) or a tricyclic combined with an antipsychotic are equally helpful. Treatments for other subtypes are discussed. Caution is necessary in people on other medication or with medical conditions. If response to an adequate trial of a first-line treatment is poor, another evidence-based treatment should be used. Second opinions are useful. Depression has a high rate of recurrence and efforts to reduce this are crucial.
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Affiliation(s)
- Peter Ellis
- Wellington School of Medicine and Health Sciences, University of Otago, Wellington, New Zealand.
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16
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Abstract
Bipolar disorder is a complex condition that includes symptoms of mania, depression, and often anxiety. Diagnosing and treating bipolar depression is challenging, with the disorder often being diagnosed as unipolar depression. In addition, comorbid anxiety can be a significant detractor to successful outcomes, increasing symptom severity, frequency of episodes and suicide rates, and decreasing response to antidepressant therapy. Anxiety often precedes and hastens the onset of bipolar disorder, and a shared genetic etiology has been suggested. Studies have demonstrated the efficacy of atypical antipsychotics for the acute and maintenance treatment of mania. Evidence from studies in patients with treatment-resistant major depressive disorder and bipolar depression indicate that these agents may also have antidepressant effects. In open trials in patients with bipolar mania, risperidone therapy has led to significant reductions in depression scores compared with baseline. Reductions in depression scores in patients with bipolar mania have been significantly greater with olanzapine compared with placebo. In patients with bipolar depression, the combination of olanzapine and fluoxetine resulted in significant improvement in depression compared with olanzapine alone or placebo. Although little data are available on the effects of these agents on comorbid anxiety in patients with bipolar disorder, some atypical antipsychotics have demonstrated efficacy in patients with anxiety disorders, including obsessive-compulsive disorder, post-traumatic stress disorder, and generalized anxiety disorder. Thus, atypical antipsychotics represent an important therapeutic option for the treatment of bipolar disorder, providing improvements in manic, depressive, and anxiety symptoms.
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Affiliation(s)
- Roger McIntyre
- Mood Disorder Psychopharmacology Unit, University of Toronto, University Health Network, Toronto Western Hospital, 399 Bathurst Street, ECW-3D-003, Toronto, Ontario, M5T 2S9, Canada.
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17
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Abstract
Fear is an adaptive component of the acute "stress" response to potentially-dangerous (external and internal) stimuli which threaten to perturb homeostasis. However, when disproportional in intensity, chronic and/or irreversible, or not associated with any genuine risk, it may be symptomatic of a debilitating anxious state: for example, social phobia, panic attacks or generalized anxiety disorder. In view of the importance of guaranteeing an appropriate emotional response to aversive events, it is not surprising that a diversity of mechanisms are involved in the induction and inhibition of anxious states. Apart from conventional neurotransmitters, such as monoamines, gamma-amino-butyric acid (GABA) and glutamate, many other modulators have been implicated, including: adenosine, cannabinoids, numerous neuropeptides, hormones, neurotrophins, cytokines and several cellular mediators. Accordingly, though benzodiazepines (which reinforce transmission at GABA(A) receptors), serotonin (5-HT)(1A) receptor agonists and 5-HT reuptake inhibitors are currently the principle drugs employed in the management of anxiety disorders, there is considerable scope for the development of alternative therapies. In addition to cellular, anatomical and neurochemical strategies, behavioral models are indispensable for the characterization of anxious states and their modulation. Amongst diverse paradigms, conflict procedures--in which subjects experience opposing impulses of desire and fear--are of especial conceptual and therapeutic pertinence. For example, in the Vogel Conflict Test (VCT), the ability of drugs to release punishment-suppressed drinking behavior is evaluated. In reviewing the neurobiology of anxious states, the present article focuses in particular upon: the multifarious and complex roles of individual modulators, often as a function of the specific receptor type and neuronal substrate involved in their actions; novel targets for the management of anxiety disorders; the influence of neurotransmitters and other agents upon performance in the VCT; data acquired from complementary pharmacological and genetic strategies and, finally, several open questions likely to orientate future experimental- and clinical-research. In view of the recent proliferation of mechanisms implicated in the pathogenesis, modulation and, potentially, treatment of anxiety disorders, this is an opportune moment to survey their functional and pathophysiological significance, and to assess their influence upon performance in the VCT and other models of potential anxiolytic properties.
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Affiliation(s)
- Mark J Millan
- Psychopharmacology Department, Centre de Rescherches de Croissy, Institut de Recherches (IDR) Servier, 125 Chemin de Ronde, 78290 Croissy-sur-Seine, Paris, France.
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