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National Institute of Mental Health Treatment of Depression Collaborative Research Program. General effectiveness of treatments
Abstract
We investigated the effectiveness of two brief psychotherapies, interpersonal psychotherapy and cognitive behavior therapy, for the treatment of outpatients with major depression disorder diagnosed by Research Diagnostic Criteria. Two hundred fifty patients were randomly assigned to one of four 16-week treatment conditions: interpersonal psychotherapy, cognitive behavior therapy, imipramine hydrochloride plus clinical management (as a standard reference treatment), and placebo plus clinical management. Patients in all treatments showed significant reduction in depressive symptoms and improvement in functioning over the course of treatment. There was a consistent ordering of treatments at termination, with imipramine plus clinical management generally doing best, placebo plus clinical management worst, and the two psychotherapies in between but generally closer to imipramine plus clinical management. In analyses carried out on the total samples without regard to initial severity of illness (the primary analyses), there was no evidence of greater effectiveness of one of the psychotherapies as compared with the other and no evidence that either of the psychotherapies was significantly less effective than the standard reference treatment, imipramine plus clinical management. Comparing each of the psychotherapies with the placebo plus clinical management condition, there was limited evidence of the specific effectiveness of interpersonal psychotherapy and none for cognitive behavior therapy. Superior recovery rates were found for both interpersonal psychotherapy and imipramine plus clinical management, as compared with placebo plus clinical management. On mean scores, however, there were few significant differences in effectiveness among the four treatments in the primary analyses. Secondary analyses, in which patients were dichotomized on initial level of severity of depressive symptoms and impairment of functioning, helped to explain the relative lack of significant findings in the primary analyses. Significant differences among treatments were present only for the subgroup of patients who were more severely depressed and functionally impaired; here, there was some evidence of the effectiveness of interpersonal psychotherapy with these patients and strong evidence of the effectiveness of imipramine plus clinical management. In contrast, there were no significant differences among treatments, including placebo plus clinical management, for the less severely depressed and functionally impaired patients.
... Following the model used in previous psychopharmacologic treatment trials, a randomized placebo-controlled efficacy methodology was applied to a comparison of IPT, cognitive-behavioral therapy (CBT), imipramine, and placebo for the treatment of major depressive disorder (as defined in DSM-III). The National Institute of Mental Health Treatment of Depression Collaborative Research Program (NIMH-TDCRP) determined that imipramine, IPT, and CBT were all superior to placebo, with imipramine superior to both IPT and CBT for severe depression (Elkin et al., 1989). None of the four interventions prevented relapse when they were terminated after 16 weeks, as required by the protocol (Elkin et al., 1989). ...
... The National Institute of Mental Health Treatment of Depression Collaborative Research Program (NIMH-TDCRP) determined that imipramine, IPT, and CBT were all superior to placebo, with imipramine superior to both IPT and CBT for severe depression (Elkin et al., 1989). None of the four interventions prevented relapse when they were terminated after 16 weeks, as required by the protocol (Elkin et al., 1989). ...
Interpersonal psychotherapy (IPT) is an empirically validated treatment for mood disorders, anxiety disorders, eating disorders, and trauma. IPT is based on the concept of “relational frame”—that an individual's experience of psychological distress impacts those around them, and that their social support network impacts the distressed individual. This concept, along with the specific techniques and tools that flow from it and the theoretical bases of IPT (attachment and interpersonal theory) make IPT unique. In this article we review the theoretical bases of IPT (attachment and communication) and provide a brief history of IPT, as well as the evidence supporting its use for a variety of disorders. We also describe its application to groups, adolescents, and other diverse populations. Future directions for research and treatment development are proposed, particularly research in the area of combining IPT with other psychotherapeutic modalities.
... This corroborates the WHO [73] finding that generally depression predominantly affect more women than men. In the USA, depression occurs about twice among women (11%) than men (6%) [74] . Young adults (16-29y) have higher levels of depression than other age groups in this study. ...
... Young adults (16-29y) have higher levels of depression than other age groups in this study. This is in agreement with a study in the USA which found that individuals aged 18-25 (17.0%) have the highest prevalence of adults with a major depressive episode [74] . This study has some limitations which should be considered when interpreting the results, including that it was conducted among people currently enrolled in an eye clinic for treatment and may have resulted in selection bias since the participants may be patients who are aware, health conscious or have the resources to access eye care services. ...
AIM: To evaluate the quality of life (QOL) and level of depression among participants with high myopia in Nigeria and the demographic factors associated with these outcomes. • METHODS: This cross-sectional study was conducted on 100 adult participants with high myopia (defined as refractive error ≤-5.00 D or worse, and uncorrected visual acuity worse than 6/18 in the better seeing eye) attending ophthalmology centres in Nigeria from 2 October 2021 to 30 August 2022. The means and standard deviations were calculated for each of the four domains of World Health Organization Quality of life scale (WHOQOL-BREF) using the transformed scores. The Beck Depression Inventory (BDI) scale was used to assess the level of depression. • RESULTS: The highest and the lowest mean scores of WHOQOL-BREF domains were found for the psychological and physical health domains (mean percentage scores were 67.0 [95% confidence intervals (CI) 64.1-68.9] and 55.3 (95%CI 51.8-58.8, P<0.001), respectively. One-way analysis of variance (ANOVA) revealed significant differences in physical health with educational status (higher among those with tertiary education: mean difference 0.9, 95%CI-0.2-2.1; P=0.049), differences in psychological health with working status (higher among those who were working 1.2, 95%CI 0.3-2.1; P=0.012). Also, the result showed a statistically significant association between environmental health and marital status (higher among non-married: 1.7, 95%CI-0.9-2.3; P=0.012) while overall health was associated with place of residence (higher in urban areas: 2.3, 95%CI 1.2-3.5; P=0.024). For depression, one in every nine participants reported major depressive symptom, mostly younger people (aged 16-29 vs 30-49y: 17.0% vs 0, P=0.019), and slightly more women than men (14.3% vs 0, P=0.064). There were significant negative correlations between the depression scores and psychological health (r=-0.48, P<0.001), physical health (r=-0.29, P=0.002), social and relationship (r=-0.49, P<0.001), environmental (r=-0.48, P<0.001) and overall health (r=-0.49, P<0.001) • CONCLUSION: People with high myopia have a relatively moderate QOL, but poor physical health, particularly the younger age group, and women who are more likely to experience clinically relevant depression. Eye care professionals should consider possible referrals for counselling for people with high myopia. • KEYWORDS: myopia; uncorrected refractive error; vision impairment; low vision; quality of life; Africa
... We assessed CBT skill using the Cognitive Therapy Rating Scale (CTRS) [11,12]. The CTRS is often considered the gold standard for behaviorally assessing CBT delity, and has been validated in general psychiatric outpatient [13] and community mental health samples [10,12]. The CTRS is comprised of 11 items, and is rated on a zero to six Likert scale. ...
Background Evidence based practices such as cognitive behavioral therapy (CBT) are often underutilized in community mental health settings. Implementation efforts can be effective in increasing CBT use among clinicians, but not all therapists successfully reach CBT competence at the end of training. Past studies have focused on how clinicians overall acquire CBT skills, rather than examining different learning trajectories that clinicians may follow and predictors of those trajectories; however, understanding of learning trajectories may suggest targets for implementation strategies. Methods We used growth mixture models to identity trajectories in CBT skill acquisition among clinicians (n = 812) participating in a large scale CBT training and implementation program, and examined predictors (attitudes towards EBPs, clinician burnout ,professional field, presence of a graduate degree) of trajectory membership. We assessed model fit using BIC, Vuong likelihood tests, and entropy. Results Consistent with our hypotheses, clinicians followed either a progressive trajectory with steady increases in CBT skills over time, or a stagnant trajectory with minimal increases in CBT skills. Clinicians with more positive attitudes towards EBPs were 3.51 times more likely to follow a progressive trajectory, while clinicians who selected ‘Other’ as a professional field predicted were 0.46 times less likely to follow a progressive trajectory. Contrary to our hypotheses, presence of a graduate degree and clinician burnout did not predict CBT trajectories. Conclusion Our results indicate that attitudes towards EBPs can be an important intervention point to improve CBT skill acquisition for therapists in training and implementation efforts. More structured support for clinicians who did not receive training in mental health focused fields may also help improve CBT learning.
... Nonignorably missing data is of particular concern in depression trials because it is very likely that the reason for a participant missing an assessment or dropping out of a study is related to their underlying depression status [Blackburn et al. (1981), Elkin et al. (1989), Warden et al. (2009)]. For example, a depressed participant may feel like the intervention is not working for them and may be unwilling to sit through an interview and/or answer the phone. ...
We present a framework for generating multiple imputations for continuous data when the missing data mechanism is unknown. Imputations are generated from more than one imputation model in order to incorporate uncertainty regarding the missing data mechanism. Parameter estimates based on the different imputation models are combined using rules for nested multiple imputation. Through the use of simulation, we investigate the impact of missing data mechanism uncertainty on post-imputation inferences and show that incorporating this uncertainty can increase the coverage of parameter estimates. We apply our method to a longitudinal clinical trial of low-income women with depression where nonignorably missing data were a concern. We show that different assumptions regarding the missing data mechanism can have a substantial impact on inferences. Our method provides a simple approach for formalizing subjective notions regarding nonresponse so that they can be easily stated, communicated and compared.
... As is the case for medication treatment, the apparent efficacy of the different psychosocial interventions has been inflated by publication bias, albeit largely for different reasons; large multinational pharmaceutical companies fund the majority of the placebo-controlled medication trials and exert undue influence over which trials are submitted for publication and how they are "spun," whereas the majority of the unpublished psychotherapy trials are relatively small-sample studies by inexperienced investigators who do not even submit their findings on the assumption that "null" findings will not be accepted for publication (Driessen et al. 2015). Nonetheless, even when corrected for bias, effect sizes are in the range of those observed for medications, and in the "silver bullet" studies that provide direct comparisons, cognitive therapy (DeRubeis et al. 2005), behavioral activation (BA; Dimidjian et al. 2006), interpersonal psychotherapy (IPT; Elkin et al. 1989), and (perhaps) problem solving therapy (Mynors-Wallis et al. 1995) have been shown to be as efficacious as medications and superior to pill-placebo among patients with more severe depression. We refer to these trials as silver bullet studies because they were particularly well done; samples were relatively large, and each trial pitted modalities overseen by experts with a vested interest in their preferred approach against one another. ...
Depression is an eminently treatable disorder that responds to psychotherapy or medications; the efficacy of each has been established in hundreds of controlled trials. Nonetheless, the prevalence of depression has increased in recent years despite the existence of efficacious treatments—a phenomenon known as the treatment–prevalence paradox. We consider several possible explanations for this paradox, which range from a misunderstanding of the very nature of depression, inflated efficacy of the established treatments, and a lack of access to efficacious delivery of treatments. We find support for each of these possible explanations but especially the notion that large segments of the population lack access to efficacious treatments that are implemented as intended. We conclude by describing the potential of using lay therapists and digital technologies to overcome this lack of access and to reach historically underserved populations and simultaneously guarantee the quality of the interventions delivered.
The evolution of psychotherapeutic treatments from Freud to digitally administered evidence-based treatments reflects a history of progressive advance. This history is characterized by identification of problems with the current state of the art, followed by solutions inspired and supported by advances in basic science and technology leading to subsequent recognition of other limitations revealed by the new advance. The common thread running through this process is (a) increasing specificity of the psychotherapeutic interventions, (b) increasing evidence of efficacy and safety, (c) increasing integrity and reliability in the delivery of the intervention, (d) increased equality of access, and (e) recognition of the need for regulation to provide protection for the public from unsafe or ineffective products. This evolution of psychotherapeutic treatments, not surprisingly, has been foreshadowed by the precursor history of the evolution of pharmacologic treatment. Although intellectual history is lumpy and does not sort itself into discrete and coherent epochs, such sorting is a useful heuristic for describing the advance of medicine and the therapeutic enterprise. This paper will discuss six successive epochs of psychotherapy. For each it will discuss the problem of the preceding era it sought to solve, the advance it brought to the field, the emerging science and technology that supported that advance, and the precursor development in pharmacological treatments that foreshadowed that epoch of psychotherapy. Finally, it will conclude with some observations about the proximate future.
Interpersonal psychotherapy (IPT) and antidepressant medications are both first-line interventions for adult depression, but their relative efficacy in the long term and on outcome measures other than depressive symptomatology is unknown. Individual participant data (IPD) meta-analyses can provide more precise effect estimates than conventional meta-analyses. This IPD meta-analysis compared the efficacy of IPT and antidepressants on various outcomes at post-treatment and follow-up (PROSPERO: CRD42020219891). A systematic literature search conducted May 1st, 2023 identified randomized trials comparing IPT and antidepressants in acute-phase treatment of adults with depression. Anonymized IPD were requested and analyzed using mixed-effects models. The prespecified primary outcome was post-treatment depression symptom severity. Secondary outcomes were all post-treatment and follow-up measures assessed in at least two studies. IPD were obtained from 9 of 15 studies identified ( N = 1536/1948, 78.9%). No significant comparative treatment effects were found on post-treatment measures of depression ( d = 0.088, p = 0.103, N = 1530) and social functioning ( d = 0.026, p = 0.624, N = 1213). In smaller samples, antidepressants performed slightly better than IPT on post-treatment measures of general psychopathology ( d = 0.276, p = 0.023, N = 307) and dysfunctional attitudes ( d = 0.249, p = 0.029, N = 231), but not on any other secondary outcomes, nor at follow-up. This IPD meta-analysis is the first to examine the acute and longer-term efficacy of IPT v . antidepressants on a broad range of outcomes. Depression treatment trials should routinely include multiple outcome measures and follow-up assessments.
A terapia cognitivo-comportamental (TCC) é uma intervenção eficaz e bem estabelecida no tratamento da depressão. Esta revisão sistemática examina as evidências atuais sobre a eficácia da TCC no manejo da depressão, além de explorar futuras direções de pesquisa nesta área. Os resultados demonstram consistentemente que a TCC reduz os sintomas depressivos e melhora o funcionamento psicossocial dos pacientes. A personalização do tratamento e a identificação de fatores de previsão de resposta são áreas importantes para futuras investigações. Além disso, a adaptação cultural da TCC e sua aplicabilidade em populações específicas, como adolescentes e idosos, merecem atenção. Em conclusão, a TCC representa uma ferramenta valiosa no tratamento da depressão, e investir em pesquisa e implementação de políticas que promovam seu acesso e qualidade é essencial para enfrentar o ônus global da depressão e melhorar os resultados dos pacientes.
Change process research in psychotherapy is the study of the processes by which change occurs in psychotherapy. Since depression is a problem with high prevalence and various complications, it is an unavoidable task for clinicians to be able to understand how the process of change occurs in patients with this diagnosis. Therefore, this study aims to carry out a systematic review of the literature, to explore and analyze the empirical investigation of the process of change in individual psychotherapy in adulthood in patients with depression, in the last ten years. The review was carried out in the Web of Science, APA PsycNet, PubMed and EBSCO databases, following the guidelines indicated by the PRISMA methodology. After the screening and review process, 39 articles were selected and analyzed. There is a clear tendency to use mixed research methodologies, that is, qualitative and quantitative, with longitudinal designs in almost all the studies and a wide range of instruments for data collection. The results suggest that the change process tends to follow a non-linear development, commonly causing deep positive changes in diverse areas and with trajectories that tend to common patterns.
Keywords: change process research, psychotherapy, depression, systematic review
A multiple comparison rank sum test by Steel [1960], for the simultaneous comparison of all pairs of treatments in a one-way classification was extended by Dunn [1964] through asymptotic use of the normal tables. Following her suggestion that the rank sum methods are appropriate for use with contingency tables, it is demonstrated that the rank sum method statistic is essentially the `regularly' calculated χ2 statistic for `moderately' large sample size. Thus a test comparable to the recommended rank sum test is achieved by comparing the usual χ2 statistic from the non-independent 2 X 2 tables with tabled χ2 1(1 - α/2p) rather than χ2 1(1 - α) for an overall α significance.