Continuation treatment of chronic depression: a comparison of nefazodone, cognitive behavioral analysis system of psychotherapy, and their combination.

Department of Psychiatry, Weill-Cornell Medical College, New York, NY 10021, USA.
Psychopharmacology bulletin (Impact Factor: 0.5). 02/2003; 37(4):73-87.
Source: PubMed


Little is known about the relative benefits of psychotherapy, medication, and combined treatment as continuation therapies for chronic forms of major depressive disorder (MDD) after a positive response to acute treatment. We hypothesize that combined treatment would demonstrate superior continuation phase outcomes compared to either monotherapy, as evidenced by lower relapse rates and greater rates of improvement from partial to full remission. We report 16-week continuation phase outcomes for 324 patients who had participated in either the acute phase of a randomized multicenter trial of nefazodone, Cognitive Behavioral Analysis System of Psychotherapy (CBASP), or combination therapy (COMB) for chronic forms of MDD. Patients entering the continuation phase had either fully or partially remitted after 12 weeks of acute phase treatment. The primary efficacy measure was the 24-item Hamilton Rating Scale for Depression. For patients in remission at acute phase exit, 73.3% (107/146) maintained their remitted status at endpoint of the continuation phase. Of those having a partial remission at acute phase exit, 52.9% (92/174) achieved full remission by end of continuation. A greater proportion of patients maintained a partial or full remission status on COMB (90%) compared to nefazodone (80%, p=0.011) or to CBASP (82%, p=0.042). These differences reflected greater symptom re-emergence in the partial remission groups on CBASP and nefazodone monotherapy compared to COMB. Continuation treatment assignment was not randomized or blinded. There was no placebo group. Most patients with chronic forms of MDD sustained their acute phase response and more than 50% of partial remitters achieved full remission while continuing treatment with nefazodone, CBASP, or COMB. COMB was associated with less symptom re-emergence during the continuation phase than either monotherapy, particularly for partial remitters.

Download full-text


Available from: John C Markowitz, May 09, 2014
  • Source
    • "This suggestion is contrary to conventional wisdom, which suggests psychotherapy is more likely to benefit non-melancholic patients. However, therapies such as Cognitive Behavior Analysis System of Psychotherapy (CBASP) (McCullough, 2000) combined with antidepressant medication have been reported to be superior to monotherapy for achieving partial or full remission in MDD (Kocsis et al., 2003). Hirschfeld et al. (2002) also found combination therapy (CBASP and nefazdone) to be more effective for improving social functioning, an improvement that appeared to be independent of depression severity. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: This study seeks to provide a comprehensive and systematic evaluation of baseline clinical and psychological features and treatment response characteristics that differentiate Major Depressive Disorder (MDD) outpatients with and without melancholic features. Reflecting the emphasis in DSM-5, we also include impairment and distress. Methods: Participants were assessed pre-treatment on clinical features (severity, risk factors, comorbid conditions, illness course), psychological profile (personality, emotion regulation), functional capacity (social and occupational function, quality of life) and distress/coping (negativity bias, emotional resilience, social skills, satisfaction with life). Participants were randomized to sertraline, escitalopram or venlafaxine extended-release and re-assessed post-treatment at 8 weeks regarding remission, response, and change in impairment and distress. Results: Patients with melancholic features (n1⁄4339; 33.7%) were distinguished clinically from non- melancholics by more severe depressive symptoms and greater exposure to abuse in childhood. Psychologically, melancholic patients were defined by introversion, and a greater use of suppression to regulate negative emotion. Melancholics also had poorer capacity for social and occupational function, and physical and psychological quality of life, along with poorer coping, reflected in less emotional resilience and capacity for social skills. Post-treatment, melancholic patients had lower remission and response, but some of this effect was due to the more severe symptoms pre-treatment. The distress/ coping outcome measure of capacity for social skills remained significantly lower for melancholic participants. Limitations: Due to the cross-sectional nature of this study, causal pathways cannot be concluded. Conclusions: Findings provide new insights into a melancholic profile of reduced ability to function interpersonally or effectively deal with one's emotions. This distinctly poorer capacity for social skills remained post-treatment. The pre-treatment profile may account for some of the difficulty in achieving remission or response with treatment.
    Journal of Affective Disorders 03/2015; 174:493-502. DOI:10.1016/j.jad.2014.10.046 · 3.38 Impact Factor
  • Source
    • "The optimal relapse prevention treatment for chronic depression is less clear. Continuation treatment using a combination of medication and cognitive behavioral therapy seems to be more effective in preventing relapse than either monotherapy (Kocsis et al. 2003), but systematic reviews to investigate the effectiveness of various treatment options are still needed to shed light on this important clinical issue (Kriston et al. 2010). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Major depressive disorder (MDD) is commonly chronic and/or recurrent. We aimed to determine whether a chronic and/or recurrent course of MDD is associated with acute and longer-term MDD treatment outcomes. This cohort study recruited out-patients aged 18-75 years with non-psychotic MDD from 18 primary and 23 psychiatric care clinics across the USA. Participants were grouped as: chronic (index episode >2 years) and recurrent (n = 398); chronic non-recurrent (n=257); non-chronic recurrent (n=1614); and non-chronic non-recurrent (n = 387). Acute treatment was up to 14 weeks of citalopram (≤ 60 mg/day) with up to 12 months of follow-up treatment. The primary outcomes for this report were remission [16-item Quick Inventory of Depressive Symptomatology - Self-Rated (QIDS-SR(16)) ≤ 5] or response (≥ 50% reduction from baseline in QIDS-SR(16)) and time to first relapse [first QIDS-SR16 by Interactive Voice Response (IVR) ≥ 11]. Most participants (85%) had a chronic and/or recurrent course; 15% had both. Chronic index episode was associated with greater sociodemographic disadvantage. Recurrent course was associated with earlier age of onset and greater family histories of depression and substance abuse. Remission rates were lowest and slowest for those with chronic index episodes. For participants in remission entering follow-up, relapse was most likely for the chronic and recurrent group, and least likely for the non-chronic, non-recurrent group. For participants not in remission when entering follow-up, prior course was unrelated to relapse. Recurrent MDD is the norm for out-patients, of whom 15% also have a chronic index episode. Chronic and recurrent course of MDD may be useful in predicting acute and long-term MDD treatment outcomes.
    Psychological Medicine 10/2011; 42(6):1131-49. DOI:10.1017/S0033291711002170 · 5.94 Impact Factor
  • Source
    • "The past 20 years have led to a clearer definition of the nature, characteristics and effects of chronic depressive disorders but treatment efficacy has not kept up with our ability to describe the phenomenon. Some pharmacological therapies have been shown to exert beneficial effects (De Lima et al., 1999; Kocsis et al., 2003; Cuijpers et al., 2010); however evidence supporting the efficacy of specific psychological therapies is, at best, modest (Stimpson et al., 2002; Cuijpers et al., 2010). Time limited, depression-specific therapies such as Interpersonal Therapy (IPT) (Klerman et al., 1974, Klerman et al., 1984) and Cognitive Behavioural Therapy for Depression (CBT-D) have been found to produce remission rates similar to those with antidepressant medication in studies of patients with acute major Contents lists available at ScienceDirect journal homepage: "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background Patients with Chronic Depression present particular challenges to psychological therapists and the evidence base for CBT with this disorder is weak. However, a large multi-centre clinical trial has demonstrated that Cognitive Behavioural Analysis System of Psychotherapy (CBASP) can be an effective therapy for chronic depression. In CBASP, patients learn how their cognitive and behavioural patterns produce and perpetuate interpersonal problems and how to alter maladaptive patterns of interpersonal behaviour. CBASP focuses primarily on problematic interpersonal situations in the everyday lives of people with chronic depression using a structured intervention called situational analysis. In addition, it places considerable emphasis on the therapeutic relationship as a vehicle for change using a methodology termed disciplined personal involvement. Clinical experience to date suggests that CBASP can be a very effective approach for a difficult to treat disorder. Objectives In this didactic workshop combining opportunities to hear/see actual CBASP therapy carried out individuals will learn about the model and therapy process and key mechanisms of change will be discussed with role-play used where appropriate to illustrate specific techniques. The theoretical model underpinning CBASP and the empirical evidence will be outlined.
    European Psychiatry 12/2009; 24. DOI:10.1016/S0924-9338(09)70255-X · 3.44 Impact Factor
Show more