Medication (Nefazodone) or psychotherapy (CBASP) is effective when the other is not

Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94305-5717, USA.
Archives of General Psychiatry (Impact Factor: 14.48). 06/2005; 62(5):513-20. DOI: 10.1001/archpsyc.62.5.513
Source: PubMed


Although various strategies are available to manage nonresponders to an initial treatment for depression, no controlled trials address the utility of switching from an antidepressant medication to psychotherapy or vice versa.
To compare the responses of chronically depressed nonresponders to 12 weeks of treatment with either nefazodone or cognitive behavioral analysis system of psychotherapy (CBASP) who were crossed over to the alternate treatment (nefazodone, n = 79; CBASP, n = 61).
Crossover trial.
Twelve academic outpatient psychiatric centers.
There were 140 outpatients with chronic major depressive disorder; 92 (65.7%) were female, 126 (90.0%) were white, and the mean age was 43.1 years. Thirty participants dropped out of the study prematurely, 22 in the nefazodone group and 8 in the CBASP group.
Treatment lasted 12 weeks. The dosage of nefazodone was 100 to 600 mg/d; CBASP was provided twice weekly during weeks 1 through 4 and weekly thereafter.
The 24-item Hamilton Rating Scale for Depression, administered by raters blinded to treatment, the Clinician Global Impressions-Severity scale, and the 30-item Inventory for Depressive Symptomatology-Self-Report.
Analysis of the intent-to-treat sample revealed that both the switch from nefazodone to CBASP and the switch from from CBASP to nefazodone resulted in clinically and statistically significant improvements in symptoms. Neither the rates of response nor the rates of remission were significantly different when the groups of completers were compared. However, the switch to CBASP following nefazodone therapy was associated with significantly less attrition due to adverse events, which may explain the higher intent-to-treat response rate among those crossed over to CBASP (57% vs 42%).
Among chronically depressed individuals, CBASP appears to be efficacious for nonresponders to nefazodone, and nefazodone appears to be effective for CBASP nonresponders. A switch from an antidepressant medication to psychotherapy or vice versa appears to be useful for nonresponders to the initial treatment.

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    • "One reason why patients do not receive CBT may be that some clinicians consider antidepressants to be superior. Five papers suggested that CBT was as good as antidepressants.11–15 Two trials have been undertaken to see the full benefits of CBT and the benefits of combination treatment.16,17 "
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    ABSTRACT: National Institute for Clinical Excellence (NICE) guidelines recommend a combination of cognitive behavioral therapy (CBT) and antidepressants to treat chronic depression. The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) is the only therapy model specifically designed for the treatment of chronic depression. To determine the clinical response to the CBASP of patients in a specialist clinical service for affective disorder and to ascertain their views on the value of the CBASP for their condition. Qualitative data from interviews including a questionnaire and objective data from Becks Depression Inventory II symptom rating scales were used to monitor the progress of a small case series of five patients with chronic, treatment refractory depression as they received the CBASP over a 10-month period. Common themes from patient interviews show very positive engagement and attitudes to the CBASP from the questionnaire. Rating scales from Becks Depression Inventory II pre- and posttreatment showed very little change for three patients with improvements between 2 and 7 points but deterioration in symptoms of 2 points for the fourth patient. The CBASP is a well-liked and positive therapy that helps patients manage their lives and deal with personal relationships, although objective data indicate little change in symptom severity.
    Psychology Research and Behavior Management 10/2012; 5:123-9. DOI:10.2147/PRBM.S31774
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    • "This near-doubling of rTMS efficacy over the last 4 years represents a significant advance towards the viability of rTMS as a firstline treatment for refractory depression. In this population, rTMS remission rates now match or exceed the 23e33% remission rates seen for an open-label second medication trial or cognitive therapy in patients failing a first medication trial in the STAR*D study [22], or the 35% response and 22% remission rates seen for patients switching to psychotherapy after failing an antidepressant medication [23]. At the same time, these advances also suggest that rTMS still has substantial scope for optimization, and that clinically meaningful improvements in rTMS efficacy may accrue with further refinements in technique. "
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    • "Patients achieving less than full remission were randomized into phase 2. Full remission was defined by concomitantly meeting the following three conditions: a) ≥ 60% reduction in Hamilton Scale for Depression [HAM-D] score, b) a 24- item HAM-D total score less than 8, and c) no longer meeting DSM-IV criteria for MDD for 2 consecutive visits during weeks 6 through 12. Phase 2 participants all received the nextstep treatment in the pharmacotherapy algorithm and were randomly assigned to one of three treatment cells in a 2:2:1 ratio: to have CBASP or BSP added to their pharmacotherapy or to receive medication alone. The 12-week duration for phase 2 mirrored the length of treatment in a previous chronic depression study by our group (Keller et al., 2000; Schatzberg et al., 2005) and the STAR*D study (Thase et al., 2007). "
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