Cognitive behavioral analysis system of psychotherapy versus interpersonal psychotherapy for early-onset chronic depression: a randomized pilot study.

BACKGROUND: The only psychotherapy specifically designed and evaluated for the treatment of chronic depression, the Cognitive Behavioral Analysis System of Psychotherapy (CBASP), has never been directly compared to another depression-specific psychological method. METHODS: Thirty patients with early-onset chronic depression were randomized to 22 sessions of CBASP or Interpersonal Psychotherapy (IPT) provided in 16 weeks. Primary outcome was the score on the 24-item Hamilton Rating Scale for Depression (HRSD) assessed posttreatment by an independent blinded evaluator. Secondary endpoints were, among others, remission (HRSD≤8) rates and the Beck Depression Inventory (BDI). The study included a prospective naturalistic 12-month follow-up. RESULTS: Intent-to-treat analyses of covariance (ANCOVA) revealed that there was no significant difference in posttreatment HRSD scores between the CBASP and the IPT condition, but in self-rated BDI scores. We found significantly higher remission rates in the CBASP (57%) as compared to the IPT (20%) group. One year posttreatment, no significant differences were found in the self-reported symptom level (BDI) using ANCOVA. LIMITATIONS: The study used only a small sample size and no placebo control. The generalizability of the results may be limited to patients with a preference for psychological treatment. CONCLUSIONS: While the primary outcome was not significant, secondary measures showed relevant benefits of CBASP over IPT. We found preliminary evidence that in early-onset chronic depression, an approach specifically designed for this patient population was superior to a method originally developed for the treatment of acute depressive episodes. Long-term results suggest that chronically depressed patients may need extended treatment courses.

Time course of response to antidepressants: predictive value of early improvement and effect of additional psychotherapy.

BACKGROUND: The full response to antidepressant pharmacotherapy is evident only after several weeks, but considerable improvements may already be visible within the first two weeks. Little is known about the potential influence of additional psychotherapy on the speed of response to antidepressant treatment. We have analysed in more severely depressed inpatients treated with antidepressants i) the predictive value of early improvement for later response and ii) the impact of additional psychotherapy on the time course of response. METHODS: 124 patients with a major depression referred for hospitalized care were randomized to 5 weeks of sertraline (or amitriptyline as a second choice) plus either additional Interpersonal Psychotherapy modified for inpatients (IPT) or Clinical Management (CM). "Improvement" was defined as a decrease of > or = 20% on the 17-item Hamilton Rating Scale for Depression (HAMD). "Onset of response" was defined as sustained improvement (without any subsequent increase in the HAMD) culminating in 50% decrease on the HAMD by week 5. RESULTS: Early improvement within two weeks was highly predictive of later stable response (> or = 50% decrease on the HAMD at weeks 4 and 5) or stable remission (HAMD score of < or = 7 at weeks 4 and 5), irrespective of the type of medication or additional IPT or CM. Survival analysis of the ITT sample revealed that patients of the IPT group had a shorter time to "onset of response" than patients in the CM group (median: 12 vs. 30 days; p=0.041, Log Rank). However, there was no significant difference in the time to onset of response, when more stringent conditions were used. LIMITATIONS: Due to ethical restrictions a comparison with an untreated placebo group could not be performed. CONCLUSIONS: Early improvement is highly predictive for later stable response or remission in more severely depressed inpatients. In combination therapy, the additional benefit of psychotherapy occurs at least as rapid as the response to antidepressants.

[The adherence of clinical management in a randomized controlled trial. Results from a psychotherapy study]. / Wie adhärent wird Clinical Management in randomisierten, kontrollierten Studien durchgeführt? Ergebnisse einer Psychotherapiestudie.

CM is increasingly used as a control condition in depression research. In the present study, the adherence of standardized CM sessions and their influence on outcome in depressed inpatients was investigated for the first time. In a randomized controlled trial, 43 inpatients with a diagnosis of Major Depression received medication treatment plus three-weekly CM sessions for 5 weeks. The 17-item version of the Hamilton Depression Rating Scale was the outcome measure. A total of 167 randomly selected audiotapes of CM sessions were evaluated using an adherence scale. The CM sessions delivered by psychiatric residents showed overall a high quality and included extensive support by the physician. The length of sessions was extended. The purity of sessions was associated with higher response rates. A diagnosis of Axis II-disorders or -traits and the clinical experience of the physician in years were predictors for less adherend treatments. However, both of them did not function as moderator variables.

Efficacy of Interpersonal Psychotherapy plus pharmacotherapy in chronically depressed inpatients.

BACKGROUND: Clinical guidelines recommend the combination of pharmaco- and psychotherapy for the treatment of chronic depression, although there are only a few studies supporting an additive effect of psychotherapy. METHODS: Forty-five inpatients with a chronic Major Depressive Disorder were randomized to 5 weeks of either Interpersonal Psychotherapy (IPT) modified for an inpatient setting (15 individual and 8 group sessions) plus pharmacotherapy or to medication plus Clinical Management (CM). The 17-item Hamilton Rating Scale for Depression was the primary outcome measure. The study included a prospective naturalistic follow-up, 3- and 12-months after discharge. RESULTS: Intent-to-treat analyses revealed a significantly greater reduction of depressive symptoms as well as better global functioning of patients treated with IPT compared to the CM group at week 5. Response and sustained response rates differed significantly between the two treatment conditions, favouring the IPT group. Remission rates were considerably higher for IPT patients who completed the treatment (67% vs. 32%). Patients who initially responded to IPT exhibited greater treatment gains at 12 months since only 7% of these subjects relapsed compared with 25% of the CM subjects. In the long-term, additional IPT led to a lower symptom level and higher global functioning. LIMITATIONS: The study uses data of a subset of patients from a larger trial. Both treatment groups did not receive comparable amounts of therapeutic attention. Extrapolating the data from this inpatient study to chronically depressed outpatients may not be possible. CONCLUSIONS: Intensive combined treatment provides superior acute and long-term effects over standard treatment in chronically depressed inpatients.

[Is interpersonal psychotherapy a woman specific method? Results of a randomized controlled study]. / Wirkt die Interpersonelle Psychotherapie besser bei Frauen als bei Männern? Ergebnisse einer randomisierten, kontrollierten Studie.

Interpersonal Psychotherapy (IPT) is considered by different authors to be a women specific therapy. If women gain more from IPT than men is not yet clear. A randomized controlled trial was conducted in 124 hospitalized patients with a DSM IV diagnosis of Major Depressive Disorder comparing 5 weeks of IPT plus medication versus medication plus Clinical Management. Pretreatment, role transitions in the family (e. g. due to motherhood) as the main problem area associated with depression were significantly more present in women whereas men described more professional changes as the main focus of depression. In addition, men had more alcohol abuse and interpersonal problems compared to women. Independent from the form of therapy, men responded faster to inpatient depression treatment. Contrary to the widespread assumption that women profit more from IPT, men in the combination treatment group revealed higher remission rates at discharge, whereas all other efficacy measures were comparable.

An intensive treatment program of interpersonal psychotherapy plus pharmacotherapy for depressed inpatients: acute and long-term results.

OBJECTIVE: The purpose of this article was to determine the relative efficacy of a psychotherapy program when combined with pharmacotherapy versus medication and clinical management in more severely depressed patients. METHOD: A randomized controlled trial was conducted in 124 hospitalized patients with DSM-IV major depressive disorder that compared 5 weeks of interpersonal psychotherapy modified for depressed inpatients (15 individual and eight group sessions) plus pharmacotherapy with a regimen that involved medication plus intensive clinical management. The study included a prospective, naturalistic follow-up 3 and 12 months after acute treatment in 97 of 105 treatment completers. The 17-item version of the Hamilton Depression Rating Scale (HAM-D) was the primary outcome measure. RESULTS: For the intent-to-treat cohort (N=124), analysis of covariance (ANCOVA) showed that patients treated with interpersonal psychotherapy had a significantly greater reduction of depressive symptoms at week 5. Response rates differed significantly between the two treatment conditions, favoring the group that received adjuvant interpersonal psychotherapy (70%) versus clinical management (51%). Remission rates also tended to be higher for patients in the interpersonal psychotherapy group (49% versus 34%). Patients who initially responded to interpersonal psychotherapy exhibited greater treatment gains at the 3-month follow-up evaluation, since only 3% of these subjects relapsed, compared with 25% of the clinical management subjects. Nine months later, this difference lost statistical significance. CONCLUSIONS: An inpatient treatment program with both brief and intensive psychotherapy plus pharmacotherapy is superior to standard treatment. The results, which add to a growing body of evidence, suggest that this combination treatment may offer an advantage over treatment with medication and clinical management for more severely depressed patients.