Clinical relevance of findings in trials of CBT for depression

Cognitive Therapy and Research, 2014

The "Dodo bird verdict," which claims that all psychotherapies are equally effective, has been a source of bewilderment and intense controversy among psychiatrists and psychologists. To examine this issue, we focused on cognitive-behavior therapy (CBT) and applied the newly developed review method known as multiple treatments meta-analysis (MTM). We identified randomized controlled trials comparing CBT against a psychological placebo (PP) and/or no treatment (NT) controls during the acute phase treatment of adults with depression. A random-effects MTM was conducted within a Bayesian framework. All the analyses were performed on an intention-to-treat basis. The MTM of the evidence network from 18 studies (39 treatment arms, 1153 participants) revealed that CBT was significantly more likely to yield a response than NT (OR = 2.24, 1.32 to 3.88) and that CBT was nominally, but not significantly, superior to PP (OR = 1.30, 0.53 to 2.94), which in turn was superior to NT (OR = 1.73, 0.67 to 4.84). The intervention effects in MTM were associated with the number of sessions, and the specificity of CBT increased as the number of sessions increased. The specific component of CBT was estimated to constitute 50.4% (19.7 to 85.0) when CBT was given for 10 or more sessions. Despite the quantitatively and qualitatively limited body of randomized evidence examining this issue, the present study strongly suggested a non-null specific component of CBT when given for an adequate length.

Psychological Medicine

Cognitive-behavioural therapy (CBT) is an effective treatment for depressed adults. CBT interventions are complex, as they include multiple content components and can be delivered in different ways. We compared the effectiveness of different types of therapy, different components and combinations of components and aspects of delivery used in CBT interventions for adult depression. We conducted a systematic review of randomised controlled trials in adults with a primary diagnosis of depression, which included a CBT intervention. Outcomes were pooled using a component-level network meta-analysis. Our primary analysis classified interventions according to the type of therapy and delivery mode. We also fitted more advanced models to examine the effectiveness of each content component or combination of components. We included 91 studies and found strong evidence that CBT interventions yielded a larger short-term decrease in depression scores compared to treatment-as-usual, with a standar...

BMC Psychiatry, 2013

Background: Depression is a major cause of disability worldwide, and computerised cognitive behavioural therapy (CCBT) is expected to be a more augmentative and efficient treatment. According to previous meta-analyses of CCBT, there is a need for a meta-analytic revaluation of the short-term effectiveness of this therapy and for an evaluation of its long-term effects, functional improvement and dropout. Methods: Five databases were used (MEDLINE, PsycINFO, EMBASE, CENTRAL and CiNii). We included all RCTs with proper concealment and blinding of outcome assessment for the clinical effectiveness of CCBT in adults (aged 18 and over) with depression. Using Cohen's method, the standard mean difference (SMD) for the overall pooled effects across the included studies was estimated with a random effect model. The main outcome measure and the relative risk of dropout were included in the meta-analysis. Results: Fourteen trials met the inclusion criteria, and sixteen comparisons from these were used for the largest meta-analysis ever. All research used appropriate random sequence generation and Intention-to-Treat analyses (ITT), and employed self-reported measures as the primary outcome. For the sixteen comparisons (2807 participants) comparing CCBT and control conditions, the pooled SMD was −0.48 [95% IC −0.63 to −0.33], suggesting similar effect to the past reviews. Also, there was no significant clinical effect at long follow-up and no improvement of function found. Furthermore, a significantly higher drop-out rate was found for CCBT than for controls. When including studies without BDI as a rating scale and with only modern imputation as sensitivity analysis, the pooled SMD remained significant despite the reduction from a moderate to a small effect. Significant publication bias was found in a funnel plot and on two tests (Begg's p = 0.09; Egger's p = 0.01). Using a trim and fill analysis, the SMD was −0.32 [95% CI −0.49 to −0.16]. Conclusion: Despite a short-term reduction in depression at post-treatment, the effect at long follow-up and the function improvement were not significant, with significantly high drop-out. Considering the risk of bias, our meta-analysis implied that the clinical usefulness of current CCBT for adult depression may need to be reconsidered downwards in terms of practical implementation and methodological validity.

IMPORTANCE 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. OBJECTIVES 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). DATA SOURCES 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. STUDY SELECTION Randomized clinical trials in which CBT and ADM were compared in patients with a DSM-defined depressive disorder were included. DATA EXTRACTION AND SYNTHESIS 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 were imputed with multiple imputation methods. Mixed-effects models adjusting for study-level differences were used to examine baseline depression severity as a moderator of treatment outcomes. MAIN OUTCOMES AND MEASURES Seventeen-item Hamilton Rating Scale for Depression (HAM-D) and Beck Depression Inventory (BDI). RESULTS There was a main effect of ADM over CBT on the HAM-D (β = −0.88; P = .03) and a nonsignificant trend on the BDI (β = −1.14; P = .08, statistical test for trend), but no significant differences in response (odds ratio [OR], 1.24; P = .12) or remission (OR, 1.18; P = .22). Mixed-effects models using the HAM-D indicated that baseline depression severity does not moderate reductions in depressive symptoms between CBT and ADM at outcome (β = 0.00; P = .96). Similar results were seen using the BDI. Baseline depression severity also did not moderate the likelihood of response (OR, 0.99; P = .77) or remission (OR, 1.00; P = .93) between CBT and ADM. CONCLUSIONS AND RELEVANCE Baseline depression severity did not moderate differences between CBT and ADM on the HAM-D or BDI or in response or remission. This finding cannot be extrapolated to other psychotherapies, to individual ADMs, or to inpatients. However, it offers new and substantial evidence that is of relevance to researchers, physicians and therapists, and patients.

International Journal of Cognitive Therapy, 2014

Journal of psychiatric practice, 2015

Cognitive-behavioral therapy (CBT) is an efficacious first-line therapy for patients with major depressive disorder (MDD). Due to the limited accessibility of CBT, long wait lists result in delayed treatment, which may affect treatment outcomes. The goal of this pilot study was to obtain preliminary data from a randomized controlled trial to determine whether delayed CBT reduces the effectiveness of the therapy compared to immediate CBT in patients with MDD receiving pharmacotherapy. Patients were randomized to receive immediate CBT (n=18) or to begin CBT after 6 months (n=20) and received 14 weekly sessions, followed by two additional booster sessions. During the active treatment months, patients in the immediate group demonstrated reductions in scores on the Beck Depression Inventory II (BDI-II) that were similar to those in the delayed CBT group. However, when the analysis was performed using only data from patients in the delayed group who were still in a depressive episode, the...

American Journal of Psychiatry, 2012

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Brain and Behavior, 2016

Background: Chronic depression is a severe and disabling condition. Compared to an episodic course, chronic depression has been shown to be less responsive to psychopharmacological and psychological treatments. The cognitive behavioral analysis system of psychotherapy (CBASP) has been developed as a specific psychotherapy for chronic depression. However, conflicting results concerning its efficacy have been reported in randomized-controlled trials (RCT). Therefore, we aimed at examining the efficacy of CBASP using meta-analytical methods. Methods: Randomized-controlled trials assessing the efficacy of CBASP in chronic depression were identified by searching electronic databases (PsycINFO, PubMed, Scopus, Cochrane Central Register of Controlled Trials) and by manual searches (citation search, contacting experts). Searching period was restricted from the first available entry to October 2015. Identified studies were systematically reviewed. The standardized mean difference Hedges' g was calculated from posttreatment and mean change scores. The random-effects model was used to compute combined overall effect sizes. A risk of publication bias was addressed using fail-safe N calculations and trim-and-fill analysis. Results: Six studies comprising 1.510 patients met our inclusion criteria. The combined overall effect sizes of CBASP versus other treatments or treatment as usual (TAU) pointed to a significant effect of small magnitude (g = 0.34-0.44, P < 0.01). In particular, CBASP revealed moderate-to-high effect sizes when compared to TAU and interpersonal psychotherapy (g = 0.64-0.75, P < 0.05), and showed similar effects when compared to antidepressant medication (ADM) (g = À0.29 to 0.02, ns). The combination of CBASP and ADM yielded benefits over antidepressant monotherapy (g = 0.49-0.59, P < 0.05). Limitations: The small number of included studies, a certain degree of heterogeneity among the study designs and comparison conditions, and insufficient data evaluating long-term effects of CBASP restrict generalizability yet. Conclusions: We conclude that there is supporting evidence that CBASP is effective in the treatment of chronic depression.

Behavioural and Cognitive Psychotherapy, 2008

Insomnia and depression are highly comorbid conditions that show a complex, bidirectional relationship. This study examined whether cognitive-behavioral therapy for insomnia (CBT-I) delivered by a therapist compared with self-help CBT-I (written materials only) reduces insomnia and depression severity in individuals with comorbid insomnia and depression. A total of 41 participants (18-64 years; 25 females) with comorbid depression and insomnia, treated with antidepressants for at least 6 weeks, were randomized to receive 4 sessions of either CBT-I or self-help CBT-I over 8 weeks. Insomnia (Insomnia Severity Index [ISI]) and depression (Beck Depression Inventory-11 [BDI-IIj) were assessed at baseline, following each session, and at 3-month follow-up. Secondary outcomes were sleep quality and duration (actigraphy and diaries), anxiety, fatigue, and daytime sleepiness. Compared with self-help CBT-I, BDI-II scores in the CBT-I group dropped by 11.93 (95% confidence interval [Cl] [6.60, 17.27], p < .001) more points, and ISI scores dropped by 6.59 (95% Cl [3.04, 10.15], p = .001) more points across treatment. At 3-month follow-up, 61.1% of CBT-I participants were in clinical remission from their insomnia and depression, compared with 5.6% of the self-help group. Conclusions: CBT-I administered by a therapist produced significant reductions in both insomnia and depression severity posttreatment and at follow-up, compared with a control condition in which participants received only written CBT-I material. Targeting insomnia through CBT-I is efficacious for treating comorbid insomnia and depres sion, and should be considered an important adjunct therapy for patients with depression whose symptoms have not remitted through antidepressant treatment.

The British journal of psychiatry : the journal of mental science, 2017

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...