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Mood Disorder Community
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Administrator
Administrator
14912 Posts
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 Posted - 05/09/2005 : 01:14:51
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Arch Gen Psychiatry. 2005 Apr;62(4):409-16.
Cognitive therapy vs medications in the treatment of moderate to severe depression.
DeRubeis RJ, Hollon SD, Amsterdam JD, Shelton RC, Young PR, Salomon RM, O'Reardon JP, Lovett ML, Gladis MM, Brown LL, Gallop R.
Department of Psychology, University of Pennsylvania, Philadelphia, PA 19104, USA. derubeis@psych.upenn.edu
BACKGROUND: There is substantial evidence that antidepressant medications treat moderate to severe depression effectively, but there is less data on cognitive therapy's effects in this population.
OBJECTIVE: To compare the efficacy in moderate to severe depression of antidepressant medications with cognitive therapy in a placebo-controlled trial.
DESIGN: Random assignment to one of the following: 16 weeks of medications (n = 120), 16 weeks of cognitive therapy (n = 60), or 8 weeks of pill placebo (n = 60).
SETTING: Research clinics at the University of Pennsylvania, Philadelphia, and Vanderbilt University, Nashville, Tenn.
PATIENTS: Two hundred forty outpatients, aged 18 to 70 years, with moderate to severe major depressive disorder.
INTERVENTIONS: Some study subjects received paroxetine, up to 50 mg daily, augmented by lithium carbonate or desipramine hydrochloride if necessary; others received individual cognitive therapy.
MAIN OUTCOME MEASURE: The Hamilton Depression Rating Scale provided continuous severity scores and allowed for designations of response and remission.
RESULTS: At 8 weeks, response rates in medications (50%) and cognitive therapy (43%) groups were both superior to the placebo (25%) group. Analyses based on continuous scores at 8 weeks indicated an advantage for each of the active treatments over placebo, each with a medium effect size. The advantage was significant for medication relative to placebo, and at the level of a nonsignificant trend for cognitive therapy relative to placebo. At 16 weeks, response rates were 58% in each of the active conditions; remission rates were 46% for medication, 40% for cognitive therapy. Follow-up tests of a site x treatment interaction indicated a significant difference only at Vanderbilt University, where medications were superior to cognitive therapy. Site differences in patient characteristics and in the relative experience levels of the cognitive therapists each appear to have contributed to this interaction.
CONCLUSION: Cognitive therapy can be as effective as medications for the initial treatment of moderate to severe major depression, but this degree of effectiveness may depend on a high level of therapist experience or expertise.
[PubMed PMID: 15809408]
[RELATED ARTICLES http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Display&dopt=pubmed_pubmed&from_uid=15809408]
Comment
There are some problems with this study.
- After 16 weeks of therapy, the remission rates reported (46% for medications and 40% for cognitive therapy) are very close to the remission rates for active placebo usually reported by other studies (i.e., 40%). In other words, neither treatment in this study seemed to be particularly effective.
- The effectiveness of the cognitive therapy depended on a high level of therapist experience or expertise (just to get remission rates equivalent to an active placebo).
- This study didn't measure social functioning, it just measured depression using a symptom checklist (the Hamilton Depression Rating Scale). This is a glaring omission.
Perhaps all we can conclude from this study is that both of their treatments were no more effective than (what you would expect from) an active placebo.
What do you think?
Phil Long M.D.
Administrator 
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| aquamarine
Amazing Member (1000+ posts)
1238 Posts
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Posted - 05/18/2005 : 16:51:25
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I am going to be bold and share how I really feel about CBT:
Personally I think that the idea that 16 weeks of CBT can alleviate the symptoms of severe and/ or chronic depression is a sham. A friend of mine who has MDD refers to the current day reverence of this treatment as, "bowing to the church of Arron Beck (the founder of CBT)". I have to agree.
My experience has been that once the depression is under control many of the CBT ideas, (goal setting, increasing activities, revisiting and doing the things you like to do when you feel well, learning to refocus and retrain your negative thoughts),may be possible. However, while you are in a Major Depressive Episode it is next to impossible to get yourself to consistently do those things.
I have always been a highly motivated and high achieving individual. I did use CBT ideas successfully for my first couple minor depressive episodes. Unfortunately, increasingly my episodes became worse and worse, my symptoms more severe and varied and the MDE's kept lasting longer. My latest episode has lasted almost 4 years and until recently remained completely treatment resistent.
During this MDE I have tried to do the CBT things. I have exercised, set weekly goals with my psychiatrist, set schedules for myself to add structure, tried to do things I usually love, forced myself to get out and be social, challenged my negative thoughts using journaling and worksheets.
Problem is because I have been so severely depressed I could not consistently DO those things. For example, I would exercise for a few weeks and manage to overcome my inertia...then suddenly one day I would succumb to such intense fatigue I could barely move. I would get on the treadmill and all I wanted to do was die, I would last maybe 5 mins sometimes. Sometimes I would sit at home and spend 2-3 hours trying to talk myself into getting up and going to the gym...which was only 5 mins away. No matter how hard I wanted to try to get well I was unable to follow through on my plans.
Recently I participated in a 12 week, (1/2 days and 5 days a week) outpatient program for people with depression and anxiety. Most of it focused on teaching participants CBT techniques: setting goals, rediscover leisure needs, socialization, thought stopping, Challenging negative thoughts etc.
For 8 of the 12 weeks I was having intensely suicidal thoughts, could not manage to achieve the 3 simple goals I would set each week, and was generally having a difficult time participating in many of the groups. I was ready to stop going because I was afraid I was getting acutely suicidal when my psychiatrist started me on Epival....as soon as I hit 1000 mgs the response was remarkable. Suddenly I saw the possibilities, I felt more comfortable, less anxious, less irritable. I was able to set goals, I began achieving my goals. There is no way it was the course. The response was immediately following the epival level hitting 1000mgs.
...Aqua |
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| aquamarine
Amazing Member (1000+ posts)
1238 Posts
Gratitude: 300
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Posted - 05/18/2005 : 17:01:07
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One more thing...(not to be a negative nelly or anything )
Those Depression index tests are (in my opinion) maybe useful to get an idea of whether someone is depressed, but as a measurement of "wellness" I don't think they are any good at all. First off...if you are a thinker your interpretation of the questions is going to skew the responses...
For example: In the Beck Depression Inventory...What exactly is the difference between wanting to die and wanting to kill yourself anyways...was always the one I got stuck on ...My wanting to kill myself indicated I wanted to die, but was the question asking was I going to kill myself? I suppose it could also be trying to determine if it was a passive thought, or active thought, or maybe it was trying to determine if I had no intentions. Who knows. Any test based on someone's interpretation is bound to be extremely subjective in terms of being a valuable tool for measurement.
I also just want to add that I believe therapy is one of the MOST valuable tools there is for depression, or any mental illness.
I have been in therapy with my psychiatrist 1 or 2 times a week since this episode began. He is very open to a wide variety of therapies. I feel that "whatever works" is his motto. His not being dogmatic about a particular therapy/treatment has helped me trust him and helped me experience and learn a great deal from all sorts of different theoretical disciplines.
Most important to me has been his unflagging support of me. I have never experienced such a completely non-judgemental, positive therapeutic relationship before. Without him I believe I would not have made it through all the medication trials I had to get through to find something that helped me. The medications are allowing me to work harder at getting better, but this relationship is helping me heal.
...Aqua |
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| PolarOne
Super Member (250+ posts)
456 Posts
Gratitude: 113
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Posted - 05/19/2005 : 12:24:19
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"remission rates reported (46% for medications and 40% for cognitive therapy) are very close to the remission rates for active placebo"
Rather depressing figures in themselves was my first thought.
I find myself tending to agree with Aqua (I don't envy you for doing that 12 week programme btw!). Treating severely depressed individuals with CBT alone strikes me as a bit brave, given motivation levels and a whole host of other factors, particularly in biological depression.
Thoughts:
Depression Rating scales have limited use in assessing actual personal progress in depression, though are a relatively simple technique for the purpose of publishing papers. My current BDI is 13 for what its worth- OK-ish.
There's so many complicating factors that can vary e.g. home situation, reaction of friends/ work to the illness, self-medication, financial worries, relationship problems and so on. Sometimes people are reluctant to talk about certain ongoing problems that may be hindering their recovery.
Obviously, not all people respond in the same way, in the same length of time, to antidepressants. Some have to try many different meds. before they find one that works for them. There are plenty more med. treatments available than the ones used in the study.
CBT is a difficult skill to learn and requires a motivated patient as well as a motivated therapist.
When I first sought treatment for Moderate Depression a few years back, I was referred by my PDoc for CBT as first-line treatment. By the time I got through the waiting list I was already very familiar with the Self-Help book, therefore the Psychologist's 5 sessions didn't really have much impact on me. 6 months later by now I started an anti-depressant and a few weeks later thats when I started to find the CBT useful. Purely motivational for me I always think. Very difficult to put into practice unless only mildly depressed I've found.
I suppose my point would be that I'd be more interested in the results of studies where all the patients were treated with appropriate meds. and the effect of CBT in addition was evaluated. Preferably over a longer period of time than 16 weeks (there are some I know!).
The other point that Aqua I think has made is to treat the individual. Resources to do this seem to be the main problem here in the UK, hence large majority treated in Primary Care setting.
Jason
"Each has his past shut in him like the leaves of a book known to him by heart and his friends can only read the title."
Virginia Woolf |
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| Nadine
Starting Member
18 Posts |
Posted - 05/25/2005 : 17:00:57
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Psychiatry also seems to believe it is better to be powerful than powerless. But until, or unless, psychiatry understands that both those positions represent polar opposites of the same error, it will never solve the problem. The solution is outside that paradigm and is to be neither all powerful nor powerless. Self control is about BOTH Self restraint and Self protection. We all want exactly the same thing: To be complete and unique individuals, as well as, equal parts of a coherent, peaceful whole which includes all of life. We want to Be the spirit of the Tao, which we already intuitively know we really are, and always have been. We all just got talked out of it by those who want us to be subordinates in an alternate reality that leads ultimately, to Non Being.
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| harryrayce
Starting Member
12 Posts |
Posted - 05/25/2005 : 18:01:48
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quote:
Originally posted by Nadine
Psychiatry also seems to believe it is better to be powerful than powerless. But until, or unless, psychiatry understands that both those positions represent polar opposites of the same error, it will never solve the problem. The solution is outside that paradigm and is to be neither all powerful nor powerless. Self control is about BOTH Self restraint and Self protection. We all want exactly the same thing: To be complete and unique individuals, as well as, equal parts of a coherent, peaceful whole which includes all of life. We want to Be the spirit of the Tao, which we already intuitively know we really are, and always have been. We all just got talked out of it by those who want us to be subordinates in an alternate reality that leads ultimately, to Non Being.
They all claim they are doing what they do for our own good. They lead the group involved, to believe the "reality" between themselves, and the one who challenges their authority, to be the exact opposite of itself. Because the group believes the aggressor, everything the victim says to them is heard through the filter of their belief system. Since telling the truth about what is happening is already pre-defined by psychiatry as "symptoms", the more the victim tells the truth, the more certain both the group, and psychiatry becomes that they "hear" symptoms of a disease process requiring their intervention. So they increase the stress, in the name of "help," until the victim's ego identity fragments under the inescapable pressure, and when that occurs, it is defined as a psychotic episode, within the parameters of a disease process, "proving" psychiatry and the group right to get the victim the "help" she so obviously needed.
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| warblaster
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Cognitive therapy vs medications
