Patient Preference as a Moderator of Outcome for Chronic Forms of Major Depressive Disorder Treated With Nefazodone, Cognitive Behavioral Analysis System of Psychotherapy, or Their Combination

Department of Psychiatry, Weill Cornell Medical College, New York, N.Y., USA.
The Journal of Clinical Psychiatry (Impact Factor: 5.14). 02/2009; 70(3):354-61. DOI: 10.4088/JCP.08m04371
Source: PubMed

ABSTRACT Little is known about moderators of response to psychotherapy, medication, and combined treatment for chronic forms of major depressive disorder (MDD). We hypothesized that patient preference at baseline would interact with treatment group to differentially affect treatment outcome.
We report outcomes for 429 patients who participated in a randomized multicenter trial of nefazodone, Cognitive Behavioral Analysis System of Psychotherapy (CBASP), or combination therapy for chronic forms of MDD (DSM-IV criteria) and who indicated their preference for type of treatment at study entry. The primary outcome measures were total scores on the 24-item Hamilton Rating Scale for Depression (HAM-D-24) and categorical definitions of remission or partial response. The patients were recruited between June 1996 and December 1997.
There was an interactive effect of preference and treatment group on outcome. The treatment effect varied as a function of preference, and was particularly apparent for patients who initially expressed preference for one of the monotherapies. Patients who preferred medication had a higher remission rate (45.5%) and lower mean HAM-D-24 score (11.6) at study exit if they received medication than if they received psychotherapy (remission rate, 22.2%; mean HAM-D-24 score, 21.0). Patients who preferred psychotherapy had a higher remission rate (50.0%) and lower mean HAM-D-24 score (12.1) if they received psychotherapy than if they received medication (remission rate 7.7%, mean HAM-D-24 score 18.3). Nevertheless, treatment preference was not associated with risk of dropout from the study.
These results suggest that patient preference is a potent moderator of treatment response for patients with chronic forms of MDD; however, relatively low proportions of the patient sample preferred one of the monotherapies, participants were not blinded to treatment assignment, and there was no placebo group.

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    • "A recent meta-analysis found that, although individuals are more likely to receive monotherapy in clinical settings, combination treatments may be a more effective treatment than monotherapy medication for certain disorders, such as depression, panic disorder, and obsessive-compulsive disorder (Cuijpers et al., 2014). In a randomized controlled multi-site trial comparing medication, psychotherapy, and combination of medication and psychotherapy among individuals with chronic depression, treatment preferences moderated treatment outcome, such that individuals who received their preferred treatment reported less depressive symptoms and higher remission rate at the end of treatment (Kocsis et al., 2009). This study highlights the importance of presenting both monotherapy and combined therapy treatment options to individuals, if consistent with the efficacy literature, as some might not do as well if they are forced to select a monotherapy, when they really wanted combination treatment or vice versa. "
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    • "In that study, assignment-preference mismatch indirectly influenced depressive symptoms at the end of treatment. Indeed, several studies have shown preference effects on outcome-relevant variables (e.g., Kocsis et al. 2009; Lin et al. 2005; Mergl et al. 2011; Moradveisi et al. 2014) as well as a greater likelihood for continuing treatment (Elkin et al. 1999), but in other studies, assignment-preference mismatch did not relate to outcomes (Dobscha et al. 2007; Dunlop et al. 2012; Leykin et al. 2007a, b). "
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    • "Our study suggests a qualification, as the effect was only observed for pharmacological treatment, and not for psychological treatment, as dropout from BA was not influenced by preference. The finding that differences between BA and pharmacotherapy in outcome as assessed with the HRSD was moderated by preference are in line with four previous studies reporting effects of preference on outcome (Kocsis et al., 2009; Mergl et al., 2011; Patricia et al., 2005; Steidtmann et al., 2012), but in contrast to the seven studies that did not find such effects (Bedi et al., 2000; Dunlop et al., 2012; Kwan et al., 2010; Laykin et al., 2007; Raue et al., 2009; Van et al., 2009; Ward et al., 2000). It is unclear which factors might explain the different findings across studies, but these might include differences between samples (e.g., primary vs. secondary care), differences between treatments that were compared, differences in designs, and different assessment methods of preferences. "
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