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: 5.5). 02/2009; 70(3):354-61. DOI: 10.4088/JCP.08m04371
Source: PubMed


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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    • "Originally we intended to conduct a three-armed RCT of MBCT alone, mADM alone or MBCT þmADM, but this turned out to be not feasible due to strong treatment preferences expressed by patients. Treatment preferences may be associated with treatment outcomes (Kocsis et al., 2009; Swift et al., 2011) and patients with strong preferences are less likely to enter RCTs if their preferences are not supported (van Schaik et al., 2004). Therefore we ended up conducting two parallel RCTs. "
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    ABSTRACT: Mindfulness-based cognitive therapy (MBCT) and maintenance antidepressant medication (mADM) both reduce the risk of relapse in recurrent depression, but their combination has not been studied. Our aim was to investigate whether the addition of MBCT to mADM is a more effective prevention strategy than mADM alone. This study is one of two multicenter randomised trials comparing the combination of MBCT and mADM to either intervention on its own. In the current trial, recurrently depressed patients in remission who had been using mADM for 6 months or longer (n=68), were randomly allocated to either MBCT+mADM (n=33) or mADM alone (n=35). Primary outcome was depressive relapse/recurrence within 15 months. Key secondary outcomes were time to relapse/recurrence and depression severity. Analyses were based on intention-to-treat. There were no significant differences between the groups on any of the outcome measures. The current study included patients who had recovered from depression with mADM and who preferred the certainty of continuing medication to the possibility of participating in MBCT. Lower expectations of mindfulness in the current trial, compared with the parallel trial, may have caused selection bias. In addition, recruitment was hampered by the increasing availability of MBCT in the Netherlands, and even about a quarter of participants included in the trial who were allocated to the control group chose to get MBCT elsewhere. For this selection of recurrently depressed patients in remission and using mADM for 6 months or longer, MBCT did not further reduce their risk for relapse/recurrence or their (residual) depressive symptoms. Copyright © 2015 Elsevier B.V. All rights reserved.
    No preview · Article · Aug 2015 · Journal of Affective Disorders
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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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    ABSTRACT: Subthreshold posttraumatic stress disorder (PTSD) is associated with impairment and has a prevalence rate comparable to full PTSD. Yet, little is known regarding treatment preferences among individuals with subthreshold PTSD, even though they seek trauma-related treatment at a similar rate to those with full PTSD. This study explored subthreshold diagnostic PTSD diagnostic category and treatment preference in undergraduate (N = 439) and trauma-exposed community (N = 203) samples. Participants completed the Posttraumatic Stress Diagnostic Scale (PDS), viewed standardized treatment rationales, and made a hypothetical PTSD treatment choice: prolonged exposure (PE), sertraline, combination treatment, or no treatment. The PDS was used to categorize individuals into four PTSD categories: no trauma exposure, trauma exposure only, subthreshold PTSD, and full PTSD. Within the samples, 8.9% (n = 39) of undergraduates and 16.7% (n = 34) of community members met subthreshold PTSD criteria. The majority of individuals with subthreshold PTSD in each sample reported impairment, 59.0% of undergraduates and 76.5% of community members. Within subthreshold PTSD groups, the most commonly selected treatments were PE (61.5%) for undergraduates and combination treatment (47.1%) for community members. Findings underscore the necessity of further examining subthreshold PTSD, which may hold important clinical implications for treatment processes and outcomes.
    Full-text · Article · Aug 2015 · Behaviour Research and Therapy
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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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    ABSTRACT: Beliefs about how much people can change their attributes - implicit theories - influence affective and cognitive responses to performance subsequent motivation. Those who believe their attributes are fixed view setbacks as threatening and avoid challenging situations. In contrast, those who believe these attributes are malleable embrace challenges as opportunities to grow. Although implicit theories would seem to have important mental health implications, the research linking them with clinical applications is limited. To address this gap, we assessed how implicit theories of anxiety, emotion, intelligence, and personality related to various symptoms of anxiety and depression, emotion-regulation strategies, and hypothetical treatment choices (e.g., medication versus therapy) in two undergraduate samples. Across both samples, individuals who believed their attributes could change reported fewer mental healths symptoms, greater use of cognitive reappraisal, and were more likely to choose individual therapy over medication. These findings suggest implicit theories may play an important role in the nature and treatment of mental health problems.
    Full-text · Article · Sep 2014 · Cognitive Therapy and Research
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