Short-term psychodynamic psychotherapy (STPP) is an empirically supported treatment that is often... more Short-term psychodynamic psychotherapy (STPP) is an empirically supported treatment that is often used to treat depression. However, it is largely unclear if certain subgroups of depressed patients can benefit specifically from this treatment method. We describe the protocol for a systematic review and meta-analysis of individual participant data (IPD) aimed at identifying predictors and moderators of STPP for depression efficacy. We will conduct a systematic literature search in multiple bibliographic databases (PubMed, PsycINFO, Embase.com, Web of Science and Cochrane's Central Register of Controlled Trials), 'grey literature' databases (GLIN and UMI ProQuest) and a prospective trial register (http://www.controlled-trials.com). We will include studies reporting (a) outcomes on standardised measures of (b) depressed (c) adult patients (d) receiving STPP. We will next invite the authors of these studies to share the participant-level data of their trials and combine thes...
Psychotherapy research : journal of the Society for Psychotherapy Research, Jan 7, 2017
A recent report from the US Institute of Medicine indicated that identifying core elements of psy... more A recent report from the US Institute of Medicine indicated that identifying core elements of psychosocial interventions is a key step in successfully bringing evidence-based psychosocial interventions into clinical practice. Component studies have the best design to examine these core elements. Earlier reviews resulted in heterogeneous sets of studies and probably missed many studies. We conducted a comprehensive search of component studies on psychotherapies for adult depression and included 16 studies with 22 comparisons. Fifteen components were examined of which four were examined in more than one comparison. The pooled difference between the full treatments and treatments with one component removed was g = 0.21 (95% CI: 0.03∼0.39). One study had sufficient statistical power to detect a small effect size and found that adding emotion regulation skills increased the effects of CBT. None of the other studies had enough power to detect an effect size smaller than g = 0.55. Only one...
There are many proven treatments (psychotherapy, pharmacotherapy or their combination) for the tr... more There are many proven treatments (psychotherapy, pharmacotherapy or their combination) for the treatment of depression. Although there is growing evidence for the effectiveness of combination treatment (psychotherapy + pharmacotherapy) over pharmacotherapy alone, psychotherapy alone or psychotherapy plus pill placebo, for depression, little is known about which specific groups of patients may respond best to combined treatment versus monotherapy. Conventional meta-analyses techniques have limitations when tasked with examining whether specific individual characteristics moderate the effect of treatment on depression. Therefore, this protocol outlines an individual patient data (IPD) meta-analysis to explore which patients, with which clinical characteristics, have better outcomes in combined treatment compared with psychotherapy (alone or with pill placebo), pharmacotherapy and pill placebo. Study searches are completed using an established database of randomised controlled trials (...
In a meta-analysis, Johnsen and Friborg (2015) reported a significant negative relationship betwe... more In a meta-analysis, Johnsen and Friborg (2015) reported a significant negative relationship between publication year and the effect sizes (ESs) of cognitive-behavioral therapy (CBT) for depressive disorders, suggesting its effectiveness was falling. We identified a series of methodological and conceptual caveats and consequently redid the meta-analysis. We used the same inclusion criteria, but only included randomized controlled trials and searched for additional eligible trials. We computed both within-group and between-group ESs for the CBT arm for the Beck Depression Inventory (BDI) and the Hamilton Rating Scale for Depression (HRSD). We assessed risk of bias, sample size, type of control group, and the study's country of origin and conducted subgroup, single, and multiple meta-regression analyses including publication year and other moderators. We identified 30 additional eligible trials. Within-group ESs presented huge heterogeneity estimates (I2 around 90%). Year of public...
The British journal of psychiatry : the journal of mental science, Mar 19, 2017
The influence of baseline severity has been examined for antidepressant medications but has not b... more The influence of baseline severity has been examined for antidepressant medications but has not been studied properly for cognitive-behavioural therapy (CBT) in comparison with pill placebo. To synthesise evidence regarding the influence of initial severity on efficacy of CBT from all randomised controlled trials (RCTs) in which CBT, in face-to-face individual or group format, was compared with pill-placebo control in adults with major depression. A systematic review and an individual-participant data meta-analysis using mixed models that included trial effects as random effects. We used multiple imputation to handle missing data. We identified five RCTs, and we were given access to individual-level data (n = 509) for all five. The analyses revealed that the difference in changes in Hamilton Rating Scale for Depression between CBT and pill placebo was not influenced by baseline severity (interaction P = 0.43). Removing the non-significant interaction term from the model, the differe...
Background: Melancholic and atypical depression are widely thought to moderate or predict outcome... more Background: Melancholic and atypical depression are widely thought to moderate or predict outcome of pharmacological and psychological treatments of adult depression, but that has not yet been established. This study uses the data from four earlier trials comparing cognitive behavior therapy (CBT) versus antidepressant medications (ADMs; and pill placebo when available) to examine the extent to which melancholic and atypical depression moderate or predict outcome in an "individual patient data" meta-analysis. Methods: We conducted a systematic search for studies directly comparing CBT versus ADM, contacted the researchers, integrated the resulting datasets from these studies into one big dataset, and selected the studies that included melancholic or atypical depressive subtyping according to DSM-IV criteria at baseline (n = 4, with 805 patients). After multiple imputation of missing data at posttest, mixed models were used to conduct the main analyses. Results: In none of the analyses was melancholic or atypical depression found to significantly moderate outcome (indicating a better or worse outcome of these patients in CBT compared to ADM; i.e., an interaction), predict outcome independent of treatment group (i.e., a main effect), or predict outcome within a given modality. The outcome differences between patients with melancholia or atypical depression versus those without were consistently very small (all effect sizes g < 0.10).
Although the average depressed patient benefits moderately from cognitive-behavioral therapy (CBT... more Although the average depressed patient benefits moderately from cognitive-behavioral therapy (CBT) or pharmacotherapy, some experience divergent outcomes. The authors tested frequencies, predictors, and moderators of negative and unusually positive outcomes. Sixteen randomized clinical trials comparing CBT and pharmacotherapy for unipolar depression in 1,700 patients provided individual pre- and posttreatment scores on the Hamilton Depression Rating Scale (HAM-D) and/or Beck Depression Inventory (BDI). The authors examined demographic and clinical predictors and treatment moderators of any deterioration (increase ≥1 HAM-D or BDI point), reliable deterioration (increase ≥8 HAM-D or ≥9 BDI points), extreme nonresponse (posttreatment HAM-D score ≥21 or BDI score ≥31), superior improvement (HAM-D or BDI decrease ≥95%), and superior response (posttreatment HAM-D or BDI score of 0) using multilevel models. About 5%-7% of patients showed any deterioration, 1% reliable deterioration, 4%-5% ...
Current guidelines recommend treating severe depression with pharmacotherapy. Randomized clinical... more Current guidelines recommend treating severe depression with pharmacotherapy. Randomized clinical trials as well as traditional meta-analyses have considerable limitations in testing for moderators of treatment outcomes. To conduct a systematic literature search, collect primary data from trials, and analyze baseline depression severity as a moderator of treatment outcomes between cognitive behavioral therapy (CBT) and antidepressant medication (ADM). A total of 14 902 abstracts were examined from a comprehensive literature search in PubMed, PsycINFO, EMBASE, and Cochrane Registry of Controlled Trials from 1966 to January 1, 2014. Randomized clinical trials in which CBT and ADM were compared in patients with a DSM-defined depressive disorder were included. Study authors were asked to provide primary data from their trial. Primary data from 16 of 24 identified trials (67%), with 1700 outpatients (794 from the CBT condition and 906 from the ADM condition), were included. Missing data ...
Background. It is not clear whether cognitive behavior therapy (CBT) works through changing dysfu... more Background. It is not clear whether cognitive behavior therapy (CBT) works through changing dysfunctional thinking. Although several primary studies have examined the effects of CBT on dysfunctional thinking, no meta-analysis has yet been conducted. Method. We searched for randomized trials comparing CBT for adult depression with control groups or with other psychotherapies and reporting outcomes on dysfunctional thinking. We calculated effect sizes of CBT versus control groups, and separately for CBT versus other psychotherapies and respectively, pharmacotherapy. Results. 26 studies across 2,002 patients met inclusion criteria. The quality of the studies was less than optimal. We found a moderate effect of CBT compared to control groups on dysfunctional thinking at post-test (g=0.50; 95% CI: 0.38~0.62), with no differences between the measures used. This result was maintained at follow-up (g=0.46; 95% CI: 0.15~0.78). There was a strong association between the effects on dysfunctional thinking and those on depression. We found no significant differences between CBT and other psychotherapies (g=0.17; p=0.31), except when restricted to the Dysfunctional Attitudes Scale (g=0.29). There also was no difference between CBT and pharmacotherapy (g=0.04), though this result was based on only 4 studies. Discussion. While CBT had a robust and stable effect on dysfunctional thoughts, this was not significantly different from what other psychotherapies or pharmacotherapy achieved. This result can be interpreted as confirming the primacy of cognitive change in symptom change irrespective of how it is attained, as well as supporting the idea that dysfunctional thoughts are simply another symptom that changes subsequent to treatment.
Many well-researched treatments for depression exist. However, there is not yet enough evidence o... more Many well-researched treatments for depression exist. However, there is not yet enough evidence on whether these therapies, designed for the treatment of depression, are also effective for reducing suicidal ideation. This research provides valuable information for researchers, clinicians, and suicide prevention policy makers. Analysis was conducted on the Treatment for Depression Research Collaborative (TDCRP) sample, which included CBT, IPT, medication, and placebo treatment groups. Participants were included in the analysis if they reported suicidal ideation on the HRSD or BDI (score of ≥1). Multivariate linear regression indicated that both IPT (b=.41, p<.05) and medication (b =.47, p<.05) yielded a significant reduction in suicide symptoms compared to placebo on the HRSD. Multivariate linear regression indicated that after adjustment for change in depression these treatment effects were no longer significant. Moderate Cohen׳s d effect sizes from baseline to post-test diffe...
Clinical practice guidelines (CPGs) are intended to improve mental, behavioral, and physical heal... more Clinical practice guidelines (CPGs) are intended to improve mental, behavioral, and physical health by promoting clinical practices that are based on the best available evidence. The American Psychological Association (APA) is committed to generating patient-focused CPGs that are scientifically sound, clinically useful, and informative for psychologists, other health professionals, training programs, policy makers, and the public. The Institute of Medicine (IOM) 2011 standards for generating CPGs represent current best practices in the field. These standards involve multidisciplinary guideline development panels charged with generating recommendations based on comprehensive systematic reviews of the evidence. The IOM standards will guide the APA as it generates CPGs that can be used to inform the general public and the practice community regarding the benefits and harms of various treatment options. CPG recommendations are advisory rather than compulsory. When used appropriately, hi...
The randomized controlled trial (RCT) provides critical support for evidence-based practice using... more The randomized controlled trial (RCT) provides critical support for evidence-based practice using psychological interventions. The control condition is the principal method of removing the influence of unwanted variables in RCTs. There is little agreement or consistency in the design and construction of control conditions. Because control conditions have variable effects, the results of RCTs can depend as much on control condition selection as on the experimental intervention. The aim of this paper is to present a framework for the selection and design of control conditions for these trials. Threats to internal validity arising from modern RCT methodology are reviewed and reconsidered. The strengths and weaknesses of several categories of control conditions are examined, including the ones that are under experimental control, the ones that are under the control of clinical service providers, and no-treatment controls. Considerations in the selection of control conditions are discuss...
Psychological Science in the Public Interest, 2002
Depression is one of the most common and debilitating psychiatric disorders and is a leading caus... more Depression is one of the most common and debilitating psychiatric disorders and is a leading cause of suicide. Most people who become depressed will have multiple episodes, and some depressions are chronic. Persons with bipolar disorder will also have manic or hypomanic episodes. Given the recurrent nature of the disorder, it is important not just to treat the acute episode, but also to protect against its return and the onset of subsequent episodes. Several types of interventions have been shown to be efficacious in treating depression. The antidepressant medications are relatively safe and work for many patients, but there is no evidence that they reduce risk of recurrence once their use is terminated. The different medication classes are roughly comparable in efficacy, although some are easier to tolerate than are others. About half of all patients will respond to a given medication, and many of those who do not will respond to some other agent or to a combination of medications....
Objective: To perform a systematic review, and if possible a meta-analysis, to establish whether ... more Objective: To perform a systematic review, and if possible a meta-analysis, to establish whether depressed patients with comorbid chronic somatic illnesses are a high risk ''double trouble'' group for depressive recurrence. Method: The databases PubMed, EMbase and PsycINFO were systematically searched until the 4 th of December 2012 by using MeSH and free text terms. Additionally, reference lists of retrieved publications and treatment guidelines were reviewed, and experts were consulted. Inclusion criteria were: depression had to be measured at least twice during the study with qualified instruments and the chronic somatic illness had to be assessed by self-report or by a medical professional. Information on depressive recurrence was extracted and additionally risk ratios of recurrence were calculated. Results: The search generated four articles that fulfilled our inclusion criteria. These studies showed no differences in recurrence over one-two-three-and 6.5 years of follow-up for a total of 2010 depressed patients of which 694 patients with a co-morbid chronic somatic illness versus 1316 patients without (Study 1: RR = 0.49, 95% CI, 0.17-1.41 at one year follow-up and RR = 1.37, 95% CI, 0.78-2.41 at two year follow-up; Study 2: RR = 0.94, 95% CI, 0.65-1.36 at two year follow-up; Study 3: RR = 1.15, 95% CI, 0.40-3.27 at one year follow-up; RR = 1.07, 95% CI, 0.48-2.42 at two year follow-up and RR = 0.99, 95% CI,0.55-1.77 at 6.5 years follow-up; Study 4: RR = 1.16, 95% CI, 0.86-1.57 at three year follow-up). Conclusion: We found no association between a heightened risk for depressive recurrence and co-morbid chronic somatic illnesses. There is a need for more longitudinal studies to justify the current specific treatment advice such as long-term pharmacological maintenance treatment for this presumed ''double trouble'' group.
Objective: A considerable number of studies has examined whether adding psychotherapy to pharmaco... more Objective: A considerable number of studies has examined whether adding psychotherapy to pharmacotherapy results in stronger effects than pharmacotherapy alone. However, earlier metaanalyses in this field have included only a limited number of available studies and did not conduct extended subgroup analyses to examine possible sources of heterogeneity. Data Sources: We used a database derived from a comprehensive literature search in PubMed, PsycINFO, EMBASE, and the Cochrane Central Register of Controlled Trials for studies published from 1966 to January 2008 that examined the psychological treatment of depression. The abstracts of these studies were identified by combining terms indicative of psychological treatment and depression. Study Selection: We included randomized trials in which the effects of a pharmacologic treatment were compared to the effects of a combined pharmacologic and psychological treatment in adults with a depressive disorder. Data Extraction: For each of the studies, we calculated a standardized mean effect size indicating the difference between pharmacotherapy and the combined treatment at posttest. We also coded major characteristics of the population, the interventions, and the quality and design of the study. Data Synthesis: Twenty-five randomized trials, with a total of 2,036 patients, were included. A mean effect size of d = 0.31 (95% CI, 0.20 ~ 0.43) was found for the 25 included studies, indicating a small effect in favor of the combined treatment over pharmacotherapy alone. Studies aimed at patients with dysthymia resulted in significantly lower effect sizes compared to studies aimed at patients with major depression, a finding that suggests that the added value of psychotherapy is less in patients with dysthymia. The dropout rate was significantly lower in the combined treatment group compared to the pharmacotherapy only group (OR = 0.65; 95% CI, 0.50 ~ 0.83). Conclusions: Psychotherapy seems to have an additional value compared to pharmacotherapy alone for depression.
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Background-The authors examined the patterns of improvement in cognitive and vegetative symptoms ... more Background-The authors examined the patterns of improvement in cognitive and vegetative symptoms of major depression in individuals treated with cognitive therapy (CT) or pharmacotherapy (PT). Method-Outpatients diagnosed with major depressive disorder (n = 180) were randomized to receive either CT or PT. Cognitive and vegetative symptoms of major depression were measured by the Beck Depression Inventory-II at baseline and regularly throughout 16 weeks of treatment. Results-Multivariate hierarchical linear modeling demonstrated the same patterns of change over time for cognitive and vegetative symptoms within CT and within PT. Limitations-Self-report measures may not be sufficiently specific to capture subtle differences in improvements between vegetative and cognitive symptoms. Conclusions-These results are consistent with Beck's (1984) hypothesis that CT and PT have a similar site of action, which when targeted, results in changes in both cognitive and vegetative features.
Background: Identifying patient characteristics that predict response within treatments (prognost... more Background: Identifying patient characteristics that predict response within treatments (prognostic) or between treatments (prescriptive) can inform clinical decision-making. In this study, we sought to identify predictors of response to evidence-based treatments in a sample of depressed patients seeking help in routine practice. Methods: Data come from a pragmatic trial of 174 patients with major depression who received an evidence-based treatment of their own choice: cognitive therapy (CT), interpersonal therapy (IPT), antidepressant medication (ADM) alone or in combination with either of the two psychotherapies. Patient characteristics measured at baseline were examined to see if they predicted subsequent response as measured with the Beck Depression Inventory (BDI) over the course of 26 weeks of treatment, using mixed regression modeling. Results: Higher agoraphobia scores at baseline predicted more change in depression scores across treatments, irrespective of the treatment received. Physical functioning moderated the response to treatment: patients with high physical functioning fared better in combined treatment than patients with low physical functioning, whereas physical functioning did not predict a differential response in the psychotherapy group. Moreover, the lowest levels of physical functioning predicted an increase of depressive symptoms in combined treatment. Limitations: A relatively small sample size, and selection of several predictors that were less theorydriven, which hampers the translation to clinical practice. Conclusions: If replicated, the prognostic and prescriptive indices identified in this study could guide decision-making in routine practice. Development of more uniform requirements for the analysis and reporting of prediction studies is recommended.
Short-term psychodynamic psychotherapy (STPP) is an empirically supported treatment that is often... more Short-term psychodynamic psychotherapy (STPP) is an empirically supported treatment that is often used to treat depression. However, it is largely unclear if certain subgroups of depressed patients can benefit specifically from this treatment method. We describe the protocol for a systematic review and meta-analysis of individual participant data (IPD) aimed at identifying predictors and moderators of STPP for depression efficacy. We will conduct a systematic literature search in multiple bibliographic databases (PubMed, PsycINFO, Embase.com, Web of Science and Cochrane's Central Register of Controlled Trials), 'grey literature' databases (GLIN and UMI ProQuest) and a prospective trial register (http://www.controlled-trials.com). We will include studies reporting (a) outcomes on standardised measures of (b) depressed (c) adult patients (d) receiving STPP. We will next invite the authors of these studies to share the participant-level data of their trials and combine thes...
Psychotherapy research : journal of the Society for Psychotherapy Research, Jan 7, 2017
A recent report from the US Institute of Medicine indicated that identifying core elements of psy... more A recent report from the US Institute of Medicine indicated that identifying core elements of psychosocial interventions is a key step in successfully bringing evidence-based psychosocial interventions into clinical practice. Component studies have the best design to examine these core elements. Earlier reviews resulted in heterogeneous sets of studies and probably missed many studies. We conducted a comprehensive search of component studies on psychotherapies for adult depression and included 16 studies with 22 comparisons. Fifteen components were examined of which four were examined in more than one comparison. The pooled difference between the full treatments and treatments with one component removed was g = 0.21 (95% CI: 0.03∼0.39). One study had sufficient statistical power to detect a small effect size and found that adding emotion regulation skills increased the effects of CBT. None of the other studies had enough power to detect an effect size smaller than g = 0.55. Only one...
There are many proven treatments (psychotherapy, pharmacotherapy or their combination) for the tr... more There are many proven treatments (psychotherapy, pharmacotherapy or their combination) for the treatment of depression. Although there is growing evidence for the effectiveness of combination treatment (psychotherapy + pharmacotherapy) over pharmacotherapy alone, psychotherapy alone or psychotherapy plus pill placebo, for depression, little is known about which specific groups of patients may respond best to combined treatment versus monotherapy. Conventional meta-analyses techniques have limitations when tasked with examining whether specific individual characteristics moderate the effect of treatment on depression. Therefore, this protocol outlines an individual patient data (IPD) meta-analysis to explore which patients, with which clinical characteristics, have better outcomes in combined treatment compared with psychotherapy (alone or with pill placebo), pharmacotherapy and pill placebo. Study searches are completed using an established database of randomised controlled trials (...
In a meta-analysis, Johnsen and Friborg (2015) reported a significant negative relationship betwe... more In a meta-analysis, Johnsen and Friborg (2015) reported a significant negative relationship between publication year and the effect sizes (ESs) of cognitive-behavioral therapy (CBT) for depressive disorders, suggesting its effectiveness was falling. We identified a series of methodological and conceptual caveats and consequently redid the meta-analysis. We used the same inclusion criteria, but only included randomized controlled trials and searched for additional eligible trials. We computed both within-group and between-group ESs for the CBT arm for the Beck Depression Inventory (BDI) and the Hamilton Rating Scale for Depression (HRSD). We assessed risk of bias, sample size, type of control group, and the study's country of origin and conducted subgroup, single, and multiple meta-regression analyses including publication year and other moderators. We identified 30 additional eligible trials. Within-group ESs presented huge heterogeneity estimates (I2 around 90%). Year of public...
The British journal of psychiatry : the journal of mental science, Mar 19, 2017
The influence of baseline severity has been examined for antidepressant medications but has not b... more The influence of baseline severity has been examined for antidepressant medications but has not been studied properly for cognitive-behavioural therapy (CBT) in comparison with pill placebo. To synthesise evidence regarding the influence of initial severity on efficacy of CBT from all randomised controlled trials (RCTs) in which CBT, in face-to-face individual or group format, was compared with pill-placebo control in adults with major depression. A systematic review and an individual-participant data meta-analysis using mixed models that included trial effects as random effects. We used multiple imputation to handle missing data. We identified five RCTs, and we were given access to individual-level data (n = 509) for all five. The analyses revealed that the difference in changes in Hamilton Rating Scale for Depression between CBT and pill placebo was not influenced by baseline severity (interaction P = 0.43). Removing the non-significant interaction term from the model, the differe...
Background: Melancholic and atypical depression are widely thought to moderate or predict outcome... more Background: Melancholic and atypical depression are widely thought to moderate or predict outcome of pharmacological and psychological treatments of adult depression, but that has not yet been established. This study uses the data from four earlier trials comparing cognitive behavior therapy (CBT) versus antidepressant medications (ADMs; and pill placebo when available) to examine the extent to which melancholic and atypical depression moderate or predict outcome in an "individual patient data" meta-analysis. Methods: We conducted a systematic search for studies directly comparing CBT versus ADM, contacted the researchers, integrated the resulting datasets from these studies into one big dataset, and selected the studies that included melancholic or atypical depressive subtyping according to DSM-IV criteria at baseline (n = 4, with 805 patients). After multiple imputation of missing data at posttest, mixed models were used to conduct the main analyses. Results: In none of the analyses was melancholic or atypical depression found to significantly moderate outcome (indicating a better or worse outcome of these patients in CBT compared to ADM; i.e., an interaction), predict outcome independent of treatment group (i.e., a main effect), or predict outcome within a given modality. The outcome differences between patients with melancholia or atypical depression versus those without were consistently very small (all effect sizes g < 0.10).
Although the average depressed patient benefits moderately from cognitive-behavioral therapy (CBT... more Although the average depressed patient benefits moderately from cognitive-behavioral therapy (CBT) or pharmacotherapy, some experience divergent outcomes. The authors tested frequencies, predictors, and moderators of negative and unusually positive outcomes. Sixteen randomized clinical trials comparing CBT and pharmacotherapy for unipolar depression in 1,700 patients provided individual pre- and posttreatment scores on the Hamilton Depression Rating Scale (HAM-D) and/or Beck Depression Inventory (BDI). The authors examined demographic and clinical predictors and treatment moderators of any deterioration (increase ≥1 HAM-D or BDI point), reliable deterioration (increase ≥8 HAM-D or ≥9 BDI points), extreme nonresponse (posttreatment HAM-D score ≥21 or BDI score ≥31), superior improvement (HAM-D or BDI decrease ≥95%), and superior response (posttreatment HAM-D or BDI score of 0) using multilevel models. About 5%-7% of patients showed any deterioration, 1% reliable deterioration, 4%-5% ...
Current guidelines recommend treating severe depression with pharmacotherapy. Randomized clinical... more Current guidelines recommend treating severe depression with pharmacotherapy. Randomized clinical trials as well as traditional meta-analyses have considerable limitations in testing for moderators of treatment outcomes. To conduct a systematic literature search, collect primary data from trials, and analyze baseline depression severity as a moderator of treatment outcomes between cognitive behavioral therapy (CBT) and antidepressant medication (ADM). A total of 14 902 abstracts were examined from a comprehensive literature search in PubMed, PsycINFO, EMBASE, and Cochrane Registry of Controlled Trials from 1966 to January 1, 2014. Randomized clinical trials in which CBT and ADM were compared in patients with a DSM-defined depressive disorder were included. Study authors were asked to provide primary data from their trial. Primary data from 16 of 24 identified trials (67%), with 1700 outpatients (794 from the CBT condition and 906 from the ADM condition), were included. Missing data ...
Background. It is not clear whether cognitive behavior therapy (CBT) works through changing dysfu... more Background. It is not clear whether cognitive behavior therapy (CBT) works through changing dysfunctional thinking. Although several primary studies have examined the effects of CBT on dysfunctional thinking, no meta-analysis has yet been conducted. Method. We searched for randomized trials comparing CBT for adult depression with control groups or with other psychotherapies and reporting outcomes on dysfunctional thinking. We calculated effect sizes of CBT versus control groups, and separately for CBT versus other psychotherapies and respectively, pharmacotherapy. Results. 26 studies across 2,002 patients met inclusion criteria. The quality of the studies was less than optimal. We found a moderate effect of CBT compared to control groups on dysfunctional thinking at post-test (g=0.50; 95% CI: 0.38~0.62), with no differences between the measures used. This result was maintained at follow-up (g=0.46; 95% CI: 0.15~0.78). There was a strong association between the effects on dysfunctional thinking and those on depression. We found no significant differences between CBT and other psychotherapies (g=0.17; p=0.31), except when restricted to the Dysfunctional Attitudes Scale (g=0.29). There also was no difference between CBT and pharmacotherapy (g=0.04), though this result was based on only 4 studies. Discussion. While CBT had a robust and stable effect on dysfunctional thoughts, this was not significantly different from what other psychotherapies or pharmacotherapy achieved. This result can be interpreted as confirming the primacy of cognitive change in symptom change irrespective of how it is attained, as well as supporting the idea that dysfunctional thoughts are simply another symptom that changes subsequent to treatment.
Many well-researched treatments for depression exist. However, there is not yet enough evidence o... more Many well-researched treatments for depression exist. However, there is not yet enough evidence on whether these therapies, designed for the treatment of depression, are also effective for reducing suicidal ideation. This research provides valuable information for researchers, clinicians, and suicide prevention policy makers. Analysis was conducted on the Treatment for Depression Research Collaborative (TDCRP) sample, which included CBT, IPT, medication, and placebo treatment groups. Participants were included in the analysis if they reported suicidal ideation on the HRSD or BDI (score of ≥1). Multivariate linear regression indicated that both IPT (b=.41, p<.05) and medication (b =.47, p<.05) yielded a significant reduction in suicide symptoms compared to placebo on the HRSD. Multivariate linear regression indicated that after adjustment for change in depression these treatment effects were no longer significant. Moderate Cohen׳s d effect sizes from baseline to post-test diffe...
Clinical practice guidelines (CPGs) are intended to improve mental, behavioral, and physical heal... more Clinical practice guidelines (CPGs) are intended to improve mental, behavioral, and physical health by promoting clinical practices that are based on the best available evidence. The American Psychological Association (APA) is committed to generating patient-focused CPGs that are scientifically sound, clinically useful, and informative for psychologists, other health professionals, training programs, policy makers, and the public. The Institute of Medicine (IOM) 2011 standards for generating CPGs represent current best practices in the field. These standards involve multidisciplinary guideline development panels charged with generating recommendations based on comprehensive systematic reviews of the evidence. The IOM standards will guide the APA as it generates CPGs that can be used to inform the general public and the practice community regarding the benefits and harms of various treatment options. CPG recommendations are advisory rather than compulsory. When used appropriately, hi...
The randomized controlled trial (RCT) provides critical support for evidence-based practice using... more The randomized controlled trial (RCT) provides critical support for evidence-based practice using psychological interventions. The control condition is the principal method of removing the influence of unwanted variables in RCTs. There is little agreement or consistency in the design and construction of control conditions. Because control conditions have variable effects, the results of RCTs can depend as much on control condition selection as on the experimental intervention. The aim of this paper is to present a framework for the selection and design of control conditions for these trials. Threats to internal validity arising from modern RCT methodology are reviewed and reconsidered. The strengths and weaknesses of several categories of control conditions are examined, including the ones that are under experimental control, the ones that are under the control of clinical service providers, and no-treatment controls. Considerations in the selection of control conditions are discuss...
Psychological Science in the Public Interest, 2002
Depression is one of the most common and debilitating psychiatric disorders and is a leading caus... more Depression is one of the most common and debilitating psychiatric disorders and is a leading cause of suicide. Most people who become depressed will have multiple episodes, and some depressions are chronic. Persons with bipolar disorder will also have manic or hypomanic episodes. Given the recurrent nature of the disorder, it is important not just to treat the acute episode, but also to protect against its return and the onset of subsequent episodes. Several types of interventions have been shown to be efficacious in treating depression. The antidepressant medications are relatively safe and work for many patients, but there is no evidence that they reduce risk of recurrence once their use is terminated. The different medication classes are roughly comparable in efficacy, although some are easier to tolerate than are others. About half of all patients will respond to a given medication, and many of those who do not will respond to some other agent or to a combination of medications....
Objective: To perform a systematic review, and if possible a meta-analysis, to establish whether ... more Objective: To perform a systematic review, and if possible a meta-analysis, to establish whether depressed patients with comorbid chronic somatic illnesses are a high risk ''double trouble'' group for depressive recurrence. Method: The databases PubMed, EMbase and PsycINFO were systematically searched until the 4 th of December 2012 by using MeSH and free text terms. Additionally, reference lists of retrieved publications and treatment guidelines were reviewed, and experts were consulted. Inclusion criteria were: depression had to be measured at least twice during the study with qualified instruments and the chronic somatic illness had to be assessed by self-report or by a medical professional. Information on depressive recurrence was extracted and additionally risk ratios of recurrence were calculated. Results: The search generated four articles that fulfilled our inclusion criteria. These studies showed no differences in recurrence over one-two-three-and 6.5 years of follow-up for a total of 2010 depressed patients of which 694 patients with a co-morbid chronic somatic illness versus 1316 patients without (Study 1: RR = 0.49, 95% CI, 0.17-1.41 at one year follow-up and RR = 1.37, 95% CI, 0.78-2.41 at two year follow-up; Study 2: RR = 0.94, 95% CI, 0.65-1.36 at two year follow-up; Study 3: RR = 1.15, 95% CI, 0.40-3.27 at one year follow-up; RR = 1.07, 95% CI, 0.48-2.42 at two year follow-up and RR = 0.99, 95% CI,0.55-1.77 at 6.5 years follow-up; Study 4: RR = 1.16, 95% CI, 0.86-1.57 at three year follow-up). Conclusion: We found no association between a heightened risk for depressive recurrence and co-morbid chronic somatic illnesses. There is a need for more longitudinal studies to justify the current specific treatment advice such as long-term pharmacological maintenance treatment for this presumed ''double trouble'' group.
Objective: A considerable number of studies has examined whether adding psychotherapy to pharmaco... more Objective: A considerable number of studies has examined whether adding psychotherapy to pharmacotherapy results in stronger effects than pharmacotherapy alone. However, earlier metaanalyses in this field have included only a limited number of available studies and did not conduct extended subgroup analyses to examine possible sources of heterogeneity. Data Sources: We used a database derived from a comprehensive literature search in PubMed, PsycINFO, EMBASE, and the Cochrane Central Register of Controlled Trials for studies published from 1966 to January 2008 that examined the psychological treatment of depression. The abstracts of these studies were identified by combining terms indicative of psychological treatment and depression. Study Selection: We included randomized trials in which the effects of a pharmacologic treatment were compared to the effects of a combined pharmacologic and psychological treatment in adults with a depressive disorder. Data Extraction: For each of the studies, we calculated a standardized mean effect size indicating the difference between pharmacotherapy and the combined treatment at posttest. We also coded major characteristics of the population, the interventions, and the quality and design of the study. Data Synthesis: Twenty-five randomized trials, with a total of 2,036 patients, were included. A mean effect size of d = 0.31 (95% CI, 0.20 ~ 0.43) was found for the 25 included studies, indicating a small effect in favor of the combined treatment over pharmacotherapy alone. Studies aimed at patients with dysthymia resulted in significantly lower effect sizes compared to studies aimed at patients with major depression, a finding that suggests that the added value of psychotherapy is less in patients with dysthymia. The dropout rate was significantly lower in the combined treatment group compared to the pharmacotherapy only group (OR = 0.65; 95% CI, 0.50 ~ 0.83). Conclusions: Psychotherapy seems to have an additional value compared to pharmacotherapy alone for depression.
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Background-The authors examined the patterns of improvement in cognitive and vegetative symptoms ... more Background-The authors examined the patterns of improvement in cognitive and vegetative symptoms of major depression in individuals treated with cognitive therapy (CT) or pharmacotherapy (PT). Method-Outpatients diagnosed with major depressive disorder (n = 180) were randomized to receive either CT or PT. Cognitive and vegetative symptoms of major depression were measured by the Beck Depression Inventory-II at baseline and regularly throughout 16 weeks of treatment. Results-Multivariate hierarchical linear modeling demonstrated the same patterns of change over time for cognitive and vegetative symptoms within CT and within PT. Limitations-Self-report measures may not be sufficiently specific to capture subtle differences in improvements between vegetative and cognitive symptoms. Conclusions-These results are consistent with Beck's (1984) hypothesis that CT and PT have a similar site of action, which when targeted, results in changes in both cognitive and vegetative features.
Background: Identifying patient characteristics that predict response within treatments (prognost... more Background: Identifying patient characteristics that predict response within treatments (prognostic) or between treatments (prescriptive) can inform clinical decision-making. In this study, we sought to identify predictors of response to evidence-based treatments in a sample of depressed patients seeking help in routine practice. Methods: Data come from a pragmatic trial of 174 patients with major depression who received an evidence-based treatment of their own choice: cognitive therapy (CT), interpersonal therapy (IPT), antidepressant medication (ADM) alone or in combination with either of the two psychotherapies. Patient characteristics measured at baseline were examined to see if they predicted subsequent response as measured with the Beck Depression Inventory (BDI) over the course of 26 weeks of treatment, using mixed regression modeling. Results: Higher agoraphobia scores at baseline predicted more change in depression scores across treatments, irrespective of the treatment received. Physical functioning moderated the response to treatment: patients with high physical functioning fared better in combined treatment than patients with low physical functioning, whereas physical functioning did not predict a differential response in the psychotherapy group. Moreover, the lowest levels of physical functioning predicted an increase of depressive symptoms in combined treatment. Limitations: A relatively small sample size, and selection of several predictors that were less theorydriven, which hampers the translation to clinical practice. Conclusions: If replicated, the prognostic and prescriptive indices identified in this study could guide decision-making in routine practice. Development of more uniform requirements for the analysis and reporting of prediction studies is recommended.
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