The efficacy of CBT for adult depression Flashcards
What are the 5 R’s to measure outcome in clinical trials?
- Response
- Remission
- Recovery
- Relapse
- Recurrence
What does (positive treatment) response correspond to?
Severity is 50% of that at the start of the treatment
What does remission correspond to?
No or few symptoms for 1-2 months
What does recovery correspond to?
Sustained remission fo between 6-12 months
- ideally, having remitted and recovered, patents will stay well
- top up CBT sessions may be offered to help sustain this remission
What does relapse correspond to?
Episode of depression after remission but before recovery
What does recurrence correspond to?
Episode of depression after recovery
What does an acute phase correspond to?
From beginning decline of patient, progression to disorder, until remission
What are the two types of predictors?
> 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
What is the typical treatment guidance for severe depression?
Antidepressant medication, not CBT
Why is antidepressant medication the typical treatment guidance for severe depression, and not CBT?
Evidence that depression severity is a moderator of CBT outcome
- meta-analyses
- but based on average group-effects across studies, not individual patient outcome
Which gap on the treatment guidance for severe depression did the meta-analysis of Weitz and colleagues (2015) address?
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
What did the individual patient-data meta-analysis of Weitz and colleagues (2015) consist of?
> 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
What were the results of the meta-analysis of Weitz and colleagues (2015)?
> 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
What are four factors that predict outcome in CBT?
- Therapist and centre expertise
- Patient characteristics
- Psychiatric co-morbidity
- Dysfunctional attitudes
What makes the therapist and centre expertise a predictor of outcome in CBD?
> 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
What makes patient characteristics a predictor of outcome in CBT?
> We know little about factors of age, gender, education
> e.g. Married vs. cohabiting patients do better than single patients
What makes psychiatric co-morbidity a predictor of outcome in CBT?
> 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
What makes dysfunctional attitudes a predictor of outcome in CBT?
High baseline levels of dysfunctional attitudes predict poor treatment outcome to CBT and medication
What are dysfunctional attitudes?
Set of general beliefs that an individual holds
Which factor has been shown to be the most important predictor of relapse in depression?
Ending treatment while patient still has residual symptoms of depression, even when meeting criterion for recovery or even short-term remission
What does the presence of residual symptoms of depression strongly predict?
Relapse
- wether original treatment is psychotherapy, or medication, or their combination
What are the various residual symptoms of depression?
- Low mood
- Irritability
- Anhedonia
- Low motivation
- Social avoidance
- Dysfunctional attitudes
- Rumination
- Sleep disturbance
