2.1 therapies for depression

Question 1

the interpersonal situation and psychotherapy

interpersonal situation

(Cain, 2024)

Psychotherapy through the lens of contemporary integrative interpersonal theory

Answer 1

a framework for psychotherapy that integrates the structural and process assumptions of CIIT - specifically:
- IS involve 2 or more people (proximal or mentally represented)
- the important psychological characteristics of IS are the perceptions of agentic and communal behaviors of self and other

goal is to provide new social learning experiences to promote change in patients’ maladaptive relational patterns

the affective valence associated with an IS is a function of one’s ability to satisfy agentic and communal motives
- when motives are satisfied → the interaction is pleasant and the behavior is reinforced
- when they are frustrated → it is unpleasant, prompting dysregulation, self-protective motives, and a need to cope and adapt

Question 2

the interpersonal situation and psychotherapy

self system and affect system

(Cain, 2024)

Psychotherapy through the lens of contemporary integrative interpersonal theory

Answer 2

Self system = organized by underlying agentic and communal interpersonal motives - lead to schemas, behavioral styles, aversions, problems, and capabilities via social learning
- Identity, self-concept, and self-worth vary based on the degree to which interpersonal motives are satisfied

Affect system = structured by affective arousal and valence - has a reciprocal relationship with the self-system
- e.g. emotional experiences provide critical feedback regarding motive satisfaction that can intensify, dull, or change the course of interpersonal behavior
- in turn, interpersonal behavior modulates affective experiences via the achievement of interpersonal goals

Question 3

the interpersonal situation and psychotherapy

interpersonal field

(Cain, 2024)

Psychotherapy through the lens of contemporary integrative interpersonal theory

Answer 3

encapsulates the relationship between the self and other + is the arena for social exchange

each person’s independent perceptions of self and other are represented as inputs, perceived in terms of their agentic and communal behaviors and impacts

within the interpersonal field, perceptual processes moderate the functioning of the self system, affect system, and behavior

Question 4

the interpersonal situation and psychotherapy

2 broad intervention strategies derived from interpersonal therapy

(Cain, 2024)

Psychotherapy through the lens of contemporary integrative interpersonal theory

Answer 4

Noncomplementary responding: recognizing the pulls of patient behavior both inside and outside of session + helps the therapist unhook from maladaptive complementary responses to patients’ interpersonal behavior
- e.g. learning to respond with curiosity and openness to patient hostility rather than act out reciprocal hostility

Therapeutic metacommunication: draws attention to the here-and-now interpersonal process playing out between therapist and patient
- then broadens to exploration of the generalizability of this pattern in the patients’ lives

Question 5

empirical support for the interpersonal situation in psychotherapy

(Cain, 2024)

Psychotherapy through the lens of contemporary integrative interpersonal theory

Answer 5

interpersonal structure:
Individual differences in patients’ interpersonal styles are related to diagnosis and patient presentation as well as therapeutic alliance and responsiveness
studies show that patients diagnosed with the same symptom disorder vary in their interpersonal styles, and these differences are associated with how core symptoms present and resolve

interpersonal processes:
several studies confirm that perception of others’ agency and communion in daily social interactions is related to the self system’s pattern of affective and behavioral responses

Question 6

training and supervision in CIIT

(Cain, 2024)

Psychotherapy through the lens of contemporary integrative interpersonal theory

Answer 6

2 key features that make CIIT a particularly useful model for training & supervision:

1. A major difference between CIIT and specific psychotherapy orientations is that CIIT is an integrative model that can accommodate theory specific techniques and relational dynamics in a common language
   = CIIT offers a model for psychotherapy and supervision regardless of the specific approach to intervention being used
2. The same kinds of dynamics occur in relationships in general, between psychotherapists and patients, and between psychotherapists and supervisors
   = CIIT principles and techniques apply similarly to supervision as they do to other kinds of relationships

Question 7

3 reasons the effects of CBT have been overestimated

(Cuijpers, 2016)

How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence

Answer 7

1. Publication bias: there is indirect evidence of publication bias in psychotherapy research, with excess publication of small studies with large effect sizes
2. Sub-optimal quality: in a meta-analysis of over 100 trials (up till 2008), only 11 met all indicators of quality, and their effect sizes were considerably smaller than those of low quality - BUT many newer studies may be of higher quality
3. Use of waitlist control groups: improvement found in patients on waiting lists has been found to be lower than that expected on the basis of spontaneous remission
   Waiting list as a ‘nocebo’ - trials using waitlist conditions considerably overestimate the ffects of psychological treatments

Question 8

method

(Cuijpers, 2016)

How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence

Answer 8

meta-analysis

focused on effects of CBT on MDD, GAD, panic disorder (PAD) & SAD

• Included randomized trials in which CBT was directly compared with a control group
• Checked the quality of the studies and the risk for bias
• They tested for publication bias

Question 9

results

(Cuijpers, 2016)

How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence

Answer 9

Overall effectiveness of CBT: CBT had large effects across all four disorders

Publication bias: issue mostly affected outcomes for GAD and MDD.

Quality of trials: the methodological quality of most studies was low or unknown

Studies with a waiting list control group showed significantly higher effect sizes than those with care-as-usual or pill placebo control groups

A higher proportion of studies conducted after 2010 were rated as high-quality compared to older studies = quality improvement in recent years

Question 10

conclusion

(Cuijpers, 2016)

How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence

Answer 10

CBT is probably effective in treating MDD, GAD, PAD, and SAD

The effects are large compared to waiting list control groups but are small to moderate when compared to more conservative control groups like care-as-usual and pill placebo

Due to the small number of high-quality studies, these findings should be approached with caution

Question 11

specific effects vs common factors

(Cuijpers, 2018)

The Role of Common Factors in Psychotherapy Outcomes

Answer 11

Majority of models explain the effectiveness of therapies through specific effects = those realized through the approach of the therapy

Common factors = factors that all therapies have in common - e.g., therapeutic alliance, empathy, expectations

Question 12

common factors: definition and models

the contextual model

(Cuijpers, 2018)

The Role of Common Factors in Psychotherapy Outcomes

Answer 12

A patient and a therapist first have to create a basic bond to work together - after the establishment of this initial bond, therapy is hypothesized to work through 3 pathways:

1. The personal relationship between therapist and patient: the extent to which each is genuine with the other and perceives/experiences the others in ways that benefit the other
2. The patient’s expectations / hope: therapies provide an explanation/rationale for how the patient developed the pathology, give hope that they are capable of finishing the therapy & provides the means to cope w their problems
3. The specific ingredients of the therapies: these create expectations in the patient, thereby activating pathway + produce beneficial actions (differ per therapy)

Question 13

do all therapies have comparable effects?

results from meta-analyses of comparative outcome studies

(Cuijpers, 2018)

The Role of Common Factors in Psychotherapy Outcomes

Answer 13

Meta-analyses of COS should first find no, or only small and non sig differences - because all therapies are assumed to have comparable effects

It is expected that there is no statistical heterogeneity (i.e., variability in effect sizes)

Mixed results from meta-analyses

Question 14

do all therapies have comparable effects?

how can differences between therapies be explained by the common factors model

(Cuijpers, 2018)

The Role of Common Factors in Psychotherapy Outcomes

Answer 14

2 explantions

1. Some therapies are not bona fide therapies: such therapies are ‘designed to fail’ and have been called ‘intent-to-fail’ treatments
   - proponents of the common factors model: only comparisons of bona fide therapies can give a fair indication of whether therapies do indeed differ significantly from each other
2. researcher allegiance: researchers w/ an allegiance toward one type of therapy are inclined to design / interpret the results of a comparative study in such a way that their preferred therapy is found to be superior to other therapies

Question 15

do all therapies have comparable effects?

alternative explanations for finding comparable outcomes

(Cuijpers, 2018)

The Role of Common Factors in Psychotherapy Outcomes

Answer 15

In general, there is little empirical evidence about how therapies work, so whether therapy works through common factors is mostly a matter of speculation

2 explanations:

1. Many roads lead to Rome: different therapies may lead to comparable outcomes via different mechanistic pathways - if a therapy focuses on one area of life and successfully changes it, then it may in turn change the other areas that are affected by the disorder
2. Randomness of interactions: both therapies and psychopathologies are complex multilayered phenomena → there are endless ways in which the therapy is shaped and these interactions differ for each patient / therapy

Question 16

How can specific and nonspecific factors be examined?

a model for the process of clinical change

(Cuijpers, 2018)

The Role of Common Factors in Psychotherapy Outcomes

Answer 16

A therapy consists of descriptive components:
- Some of which are inactive (e.g., do not contribute to change in a patient)
- Some of which are active (e.g., specific therapeutic procedures)

The therapeutic processes or events that are responsible for change and the reasons why, or how change occurs are the result of the active components of the therapies

Happen in the patient - as opposed to descriptive components that are part of the therapy

The extratherapeutic factors = events outside of therapy that influence mechanisms of change - may incl life events or a lack of competencies in the patient that limit the possibilities of the mechanisms of change

Question 17

Evidence for selected common factors

(Cuijpers, 2018)

The Role of Common Factors in Psychotherapy Outcomes

Answer 17

therapeutic alliance: most recent meta-analysis found that stronger alliances are associated with better treatment outcomes, although the magnitude is modest

other common factors: expressed empathy, the therapeutic alliance, and collecting structured client feedback were effective elements of the therapeutic relationship across all models of psychotherapy

Question 18

hypotheses

(Undurraga 2017)

Direct comparison of tricyclic and serotonin reuptake inhibitor antidepressants in randomized head-to-head trials in acute major depression: Systematic review and meta-analysis

Answer 18

Hypothesis 1: there would be little difference between the antidepressant types based on direct comparisons under matching conditions

Hypothesis 2: within-trial improvements in depression ratings among depressed individuals randomized to TCA or SSRI would not show significant secular changes over the observed reporting years
- BUT the size (sample) of trials and their duration would increase
- Also, SSRIs might be associated with lower dropout rates

Question 19

discussion

(Undurraga 2017)

Direct comparison of tricyclic and serotonin reuptake inhibitor antidepressants in randomized head-to-head trials in acute major depression: Systematic review and meta-analysis

Answer 19

Their previous meta-analysis found evidence of a greater response to TCAs than to SSRIs → contrary to earlier findings
- HOWEVER, TCAs come with the higher risk of causing excessive mood-elevation or switching from depression to mania
- The authors suggest that the superiority of TCAs may not accurately reflect the true effectiveness

This meta-analysis showed that there was no difference between drugs in ratings or improvement
- BUT this does not prove equal efficacy => the variance within and between these trials might limit the detection of relatively small differences in efficacy
- ALSO, major depression includes a range of subtypes => different types may respond differently to drugs
- SO, the conclusion of equal efficacy should be interpreted with caution

TCAs, however, were associated with more dropouts

Question 20

the model of mindfulness-based cognitive therapy (MBCT)

(Piet, 2011)

The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: A systematic review and meta-analysis

Answer 20

Specifies that previously depressed people are characterized by greater cog vulnerability to states of low mood
- Designed for prevention of relapse or recurrence among patients w MDD in remission

Mechanism of action: MBCT may work by targeting rumination and emotional avoidance - both considered to be maintaining processes across mood disorders

Has been claimed that MBCT particularly benefits patients with 3 or more MDD episodes

Question 21

MBCT process

(Piet, 2011)

The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: A systematic review and meta-analysis

Answer 21

Aim of MBCT: teach patients to become more aware of and relate differently to their experience

Mindfulness exercises (e.g. the body scan, simple yoga exercises & song meditations) used to teach patients to ‘turn inwards’ and accept intense bodily sensations / emotional discomfort

patients provided with cognitive skills to recognize the automatic activation of habitual dysfunctional cognitive processes + to ‘decentre’ from the content of neg thoughts, and to disengage from these processes by redirecting attention

Question 22

discussion & conclusion

(Piet, 2011)

The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: A systematic review and meta-analysis

Answer 22

A substantial difference in the subgroup of patients with 3+ previous episodes of MDD
- Relapse rate here was 36% compared to 63% for control conditions
- However, for participants with only 2 prior episodes of MDD there was a lower risk of relapse for TAU (treatment as usual) compared to MBCT
- Possible that MBCT may not be helpful for remitted MDD patients with a lesser degree of risk of relapse

MBCT is at least comparable to m-ADM (maintenance antidepressant medication) for effective relapse prevention of recurrent MDD with 3+ episodes

Conclusion: this meta-analysis supports use of MBCT as a low cost intervention for relapse prevention in recurrent MDD in remission, at least in case of 3+ previous episodes

Question 23

method

(Lemmens, 2020)

Interpersonal Psychotherapy Versus Cognitive Therapy for Depression: How They Work, How Long, and for Whom—Key Findings From an RCT

Answer 23

182 outpatients with a primary diagnosis of MDD

Up to 7 months of treatment phase & then up to 17 months of naturalistic follow-up phase

16-20 weekly individual 45-minute sessions

Question 24

results

IPT versus CT: how well do they work and does one outperform the other?

(Lemmens, 2020)

Interpersonal Psychotherapy Versus Cognitive Therapy for Depression: How They Work, How Long, and for Whom—Key Findings From an RCT

Answer 24

Over the course of treatment, statistically significant and clinically relevant improvements in self-reported depression severity found for both IPT and CT

Response to therapy significantly exceeded response in the waitlist control

Participants reported significant improvements in QOL and social / general functioning for both treatments

The symptom reduction achieved during the 7-month treatment phase was maintained across the follow-up for both IPT and CT

Question 25

results

IPT or CT: what works for whom?

(Lemmens, 2020)

Interpersonal Psychotherapy Versus Cognitive Therapy for Depression: How They Work, How Long, and for Whom—Key Findings From an RCT

Answer 25

Examined associations between various patient characteristics and treatment outcomes

Comorbid anxiety disorder and symptoms were associated w/ better outcomes for CT

Moderators of treatment outcomes:
- Somatic complaints
- Cognitive problems - predicted a better response to IPT
- Paranoid symptoms
- Interpersonal self-sacrificing
- Attributional style focused on achievement of goals
- Number of life events in the past year

Besides cognitive problems, the 5 remaining moderators predicted a better response to CT

Question 26

results

IPT & CT: how do they work?

(Lemmens, 2020)

Interpersonal Psychotherapy Versus Cognitive Therapy for Depression: How They Work, How Long, and for Whom—Key Findings From an RCT

Answer 26

According to the theoretical models, different mechanisms are involved in IPT and CT:
- Interpersonal therapy - assumed that improvements in interpersonal functioning are crucial for symptom improvement
- Cognitive therapy - assumed that depression severity can be reduced by altering the function, content and structure of cognitions and schemas associated with depressed mood

Question 27

conclusions

(Lemmens, 2020)

Interpersonal Psychotherapy Versus Cognitive Therapy for Depression: How They Work, How Long, and for Whom—Key Findings From an RCT

Answer 27

IPT and CT are efficacious for many patients w/depression both during acute phase and beyond
- Both interventions were superior to the waitlist condition and had outcomes that didn’t sig differ from each other

clear evidence of moderation suggest that mechanisms through change is brought about differ between CT and IPT

Patients who responded to IPT were not sig more likely to relapse after treatment termination than patients who responded to CT

Despite overall lack of difference in effectiveness, for the majority of participants, one of the interventions was predicted to be more beneficial