The efficacy of CBT for adult depression

Question 1

What are the 5 R’s to measure outcome in clinical trials?

Answer 1

1. Response
2. Remission
3. Recovery
4. Relapse
5. Recurrence

Question 2

What does (positive treatment) response correspond to?

Answer 2

Severity is 50% of that at the start of the treatment

Question 3

What does remission correspond to?

Answer 3

No or few symptoms for 1-2 months

Question 4

What does recovery correspond to?

Answer 4

Sustained remission fo between 6-12 months

• ideally, having remitted and recovered, patients will stay well
• top up CBT sessions may be offered to help sustain this remission

Question 5

What does relapse correspond to?

Answer 5

Episode of depression after remission but before recovery

Question 6

What does recurrence correspond to?

Answer 6

Episode of depression after recovery

Question 7

What does an acute phase correspond to?

Answer 7

From beginning decline of patient, progression to disorder, until remission

Question 8

What are the two types of predictors?

Answer 8

> Non-specific predictors
- associated with overall outcome regardless of treatment

> Moderator
- baseline, or other characteristics, that interact with the treatment and influence the size of the eventual treatment effect

Question 9

What is the typical treatment guidance for severe depression?

Answer 9

Antidepressant medication, not CBT

Question 10

Why is antidepressant medication the typical treatment guidance for severe depression, and not CBT?

Answer 10

Evidence that depression severity is a moderator of CBT outcome

• meta-analyses
• but based on average group-effects across studies, not individual patient outcome

Question 11

Which gap on the treatment guidance for severe depression did the meta-analysis of Weitz and colleagues (2015) address?

Answer 11

Previous meta-analyses supporting antidepressant medication for severe depression instead of CBT were based on average group-effects across studies, not individual patient outcome

-> Weitz et al. (2015): individual patient-data meta-analysis

Question 12

What did the individual patient-data meta-analysis of Weitz and colleagues (2015) consist of?

Answer 12

> 24 trials, individual data from 16

> 1700 patients CBT vs. medication

> Does baseline severity predict outcome differences between CBT and Medication?

• change in mean depression scores
• response
• remission

Question 13

What were the results of the meta-analysis of Weitz and colleagues (2015)?

Answer 13

> Depression severity does not moderate CBT outcome at individual patient level

> Patients with more severe depression show a greater response whatever the treatment

-> Antidepressant medication should not be the automatic first choice treatment for severe depression

Question 14

What are four factors that predict outcome in CBT?

Answer 14

1. Therapist and centre expertise
2. Patient characteristics
3. Psychiatric co-morbidity
4. Dysfunctional attitudes

Question 15

What makes the therapist and centre expertise a predictor of outcome in CBT?

Answer 15

> Better outcomes with more experienced therapists

> Better outcomes in specialist centres than in routine clinical settings

> Therapists skill and experience will impact efficacy
- inexperience may be a better gauge for real-world application

Question 16

What makes patient characteristics a predictor of outcome in CBT?

Answer 16

> We know little about factors of age, gender, education

> e.g. Married vs. cohabiting patients do better than single patients

Question 17

What makes psychiatric co-morbidity a predictor of outcome in CBT?

Answer 17

> Poor response where depression is present with another significant psychiatric disorder

> e.g. STAR*D trial (Farabaugh et al., 2012):

• standard antidepressant, if no response -> switch treatment (including CBT)
• patients with depression and anxiety show lower overall remission rates with both CBT and medication

-> co-morbid depression and anxiety is a non-specific predictor of poor treatment outcome, rather than the moderator of CBT outcomes specifically

Question 18

What makes dysfunctional attitudes a predictor of outcome in CBT?

Answer 18

High baseline levels of dysfunctional attitudes predict poor treatment outcome to CBT and medication

Question 19

What are dysfunctional attitudes?

Answer 19

Set of general beliefs that an individual holds

Question 20

Which factor has been shown to be the most important predictor of relapse in depression?

Answer 20

Ending treatment while patient still has residual symptoms of depression, even when meeting criterion for recovery or even short-term remission

Question 21

What does the presence of residual symptoms of depression strongly predict?

Answer 21

Relapse

- wether original treatment is psychotherapy, or medication, or their combination

Question 22

What are the various residual symptoms of depression?

Answer 22

• Low mood
• Irritability
• Anhedonia
• Low motivation
• Social avoidance
• Dysfunctional attitudes
• Rumination
• Sleep disturbance