Winter Depression Recurrence One Year After Cognitive-Behavioral Therapy, Light Therapy, or Combination Treatment

ArticleinBehavior therapy 40(3):225-38 · October 2009with35 Reads
Impact Factor: 3.69 · DOI: 10.1016/j.beth.2008.06.004 · Source: PubMed
Abstract

The central public health challenge in the management of seasonal affective disorder (SAD) is prevention of depression recurrence each fall/winter season. The need for time-limited treatments with enduring effects is underscored by questionable long-term compliance with clinical practice guidelines recommending daily light therapy during the symptomatic months each year. We previously developed a SAD-tailored group cognitive-behavioral therapy (CBT) and tested its acute efficacy in 2 pilot studies. Here, we report an intent-to-treat (ITT) analysis of outcomes during the subsequent winter season (i.e., approximately 1 year after acute treatment) using participants randomized to CBT, light therapy, and combination treatment across our pilot studies (N=69). We used multiple imputation to estimate next winter outcomes for the 17 individuals who dropped out during treatment, were withdrawn from protocol, or were lost to follow-up. The CBT (7.0%) and combination treatment (5.5%) groups had significantly smaller proportions of winter depression recurrences than the light therapy group (36.7%). CBT alone, but not combination treatment, was also associated with significantly lower interviewer- and patient-rated depression severity at 1 year as compared to light therapy alone. Among completers who provided 1-year data, all statistically significant differences between the CBT and light therapy groups persisted after adjustment for ongoing treatment with light therapy, antidepressants, and psychotherapy. If these findings are replicated, CBT could represent a more effective, practical, and palatable approach to long-term SAD management than light therapy.

    • "... rates of long-term use of prescribed bright-light therapy for SAD ranging between 11% and 42% [43,44]. Therefore, identifying an effective and efficient duration of bright-light treatment that patients..."
      Michalak and colleagues [42] reported that, over a 4-week intervention, mean adherence to the prescribed bright-light treatment was 59%. Others have reported rates of long-term use of prescribed bright-light therapy for SAD ranging between 11% and 42% [43,44]. Therefore, identifying an effective and efficient duration of bright-light treatment that patients can realistically follow is warranted.
    [Show abstract] [Hide abstract] ABSTRACT: Objective: Efficient treatments to phase-advance human circadian rhythms are needed to attenuate circadian misalignment and the associated negative health outcomes that accompany early-morning shift work, early school start times, jet lag, and delayed sleep phase disorder. This study compared three morning bright-light exposure patterns from a single light box (to mimic home treatment) in combination with afternoon melatonin. Methods: Fifty adults (27 males) aged 25.9 ± 5.1 years participated. Sleep/dark was advanced 1 h/day for three treatment days. Participants took 0.5 mg of melatonin 5 h before the baseline bedtime on treatment day 1, and an hour earlier each treatment day. They were exposed to one of three bright-light (~5000 lux) patterns upon waking each morning: four 30-min exposures separated by 30 min of room light (2-h group), four 15-min exposures separated by 45 min of room light (1-h group), and one 30-min exposure (0.5-h group). Dim-light melatonin onsets (DLMOs) before and after treatment determined the phase advance. Results: Compared to the 2-h group (phase shift = 2.4 ± 0.8 h), smaller phase-advance shifts were seen in the 1-h (1.7 ± 0.7 h) and 0.5-h (1.8 ± 0.8 h) groups. The 2-h pattern produced the largest phase advance; however, the single 30-min bright-light exposure was as effective as 1 h of bright light spread over 3.25 h, and it produced 75% of the phase shift observed with 2 h of bright light. Conclusions: A 30-min morning bright-light exposure with afternoon melatonin is an efficient treatment to phase-advance human circadian rhythms.
    Full-text · Article · Dec 2014 · Sleep Medicine
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    • "...wer depression severity on the SIGH-SAD and BDI-II the next winter as compared to solo LT (Rohan et al. 2009b). Considering these efficacy results in combination with the results reported here, it is possible ..."
      LT (5.5 %) groups both had significantly smaller proportions of winter depression recurrences than the solo LT group (36.7 %) the next winter, only solo CBT (not CBT ? LT) was associated with significantly lower depression severity on the SIGH-SAD and BDI-II the next winter as compared to solo LT (Rohan et al. 2009b). Considering these efficacy results in combination with the results reported here, it is possible that adding LT to CBT waters down the cognitive mechanism of CBT.
    [Show abstract] [Hide abstract] ABSTRACT: Efficacious treatments for seasonal affective disorder include light therapy and a seasonal affective disorder-tailored form of cognitive-behavioral therapy. Using data from a parent clinical trial, these secondary analyses examined the relationship between cognitive change over treatment with cognitive-behavioral therapy, light therapy, or combination treatment and mood outcomes the next winter. Sixty-nine participants were randomly assigned to 6-weeks of cognitive-behavioral therapy, light therapy, or combination treatment. Cognitive constructs (i.e., dysfunctional attitudes, negative automatic thoughts, and rumination) were assessed at pre- and post-treatment. Dysfunctional attitudes, negative automatic thoughts, and rumination improved over acute treatment, regardless of modality; however, in participants randomized to solo cognitive-behavioral therapy, a greater degree of improvement in dysfunctional attitudes and automatic thoughts was uniquely associated with less severe depressive symptoms the next winter. Change in maladaptive thoughts during acute treatment appears mechanistic of solo cognitive-behavioral therapy’s enduring effects the next winter, but is simply a consequence of diminished depression in light therapy and combination treatment.
    Full-text · Article · Dec 2013 · Cognitive Therapy and Research
    0Comments 2Citations
    • "...T, which proposes maladaptive cognitions contribute to SAD onset and maintenance ( Rohan, Roecklein, Lacy, et al., 2009). Components of the CBT for SAD protocol explicitly target the cognitive vulnerabilities assessed i..."
      Given the poor long-term compliance with LT, it seems particularly risky to treat SAD patients who are high in cognitive vulnerability with solo LT in terms of long-term depression outcomes. The current results are also consistent with the integrative cognitive-behavioral theory of SAD, the basis for SAD-tailored CBT, which proposes maladaptive cognitions contribute to SAD onset and maintenance ( Rohan, Roecklein, Lacy, et al., 2009). Components of the CBT for SAD protocol explicitly target the cognitive vulnerabilities assessed in the current study in that CBT requires active practice of skills taught, such as cognitive restructuring to identify and challenge negative thought content (i.e., automatic thoughts and dysfunctional attitudes) and planned engagement in pleasurable activities.
    [Show abstract] [Hide abstract] ABSTRACT: There is no empirical basis for determining which seasonal affective disorder (SAD) patients are best suited for what type of treatment. Using data from a parent clinical trial comparing light therapy (LT), cognitive-behavioral therapy (CBT), and their combination (CBT + LT) for SAD, we constructed hierarchical linear regression models to explore baseline cognitive vulnerability constructs (i.e., dysfunctional attitudes, negative automatic thoughts, response styles) as prognostic and prescriptive factors of acute and next winter depression outcomes. Cognitive constructs did not predict or moderate acute treatment outcomes. Baseline dysfunctional attitudes and negative automatic thoughts were prescriptive of next winter treatment outcomes. Participants with higher baseline levels of dysfunctional attitudes and negative automatic thoughts had less severe depression the next winter if treated with CBT than if treated with LT. In addition, participants randomized to solo LT who scored at or above the sample mean on these cognitive measures at baseline had more severe depressive symptoms the next winter relative to those who scored below the mean. Baseline dysfunctional attitudes and negative automatic thoughts did not predict treatment outcomes in participants assigned to solo CBT or CBT + LT. Therefore, SAD patients with extremely rigid cognitions did not fare as well in the subsequent winter if treated initially with solo LT. Such patients may be better suited for initial treatment with CBT, which directly targets cognitive vulnerability processes.
    Full-text · Article · Oct 2013 · Behaviour Research and Therapy
    0Comments 2Citations
    • "...re not supported. Similar to Western findings (Faramarzi et al., 2008; Hunter et al., 2002; Rohan et al., 2009), the CBT groups had similar remission rate and improvement in depressive symptoms and social funct..."
      The first and second hypotheses that CBT and MED are more effective than the ST in improving the remission rate and social functioning were not supported. Similar to Western findings (Faramarzi et al., 2008; Hunter et al., 2002; Rohan et al., 2009), the CBT groups had similar remission rate and improvement in depressive symptoms and social functioning with the MED and ST groups. Previous studies only examined the effect of CBT in mild– moderate MDD (Melvin et al., 2006).
    [Show abstract] [Hide abstract] ABSTRACT: No study has examined the effect of cognitive-behavioral therapy (CBT) on moderate-severe major depressive disorders (MDD) in China. The objective of this study was to evaluate the effect of CBT, antidepressants alone (MED), combined CBT and antidepressants (COMB) and standard treatment (ST; i.e., receiving psycho-educational intervention and/or medication treatment determined by treating psychiatrists) on depressive symptoms and social functioning in Chinese patients with moderate-severe MDD. A total of 180 patients diagnosed with MDD according to ICD-10 were randomly allocated to one of the four treatment regimens for a period of 6 months. Depressive symptoms were measured using the Hamilton Rating Scale for Depression (HAMD) and the Quick Inventory of Depressive Symptomatology-Self-Report (C-QIDS-SR). Remission threshold was defined as a C-QIDS-SR total score of <5. Social functioning was evaluated with the Work and Social Adjustment Scale (WSAS). All outcome measures were evaluated at entry, and at 3- and 6-months follow-up. At the 6-months assessment, the remission rates in the whole sample (n=96), the MED, the CBT, the COMB and the ST groups were 54.2%, 48%, 75%, 53.5% and 50%, respectively. Following the treatment periods, there was no significant difference in any of the study outcomes between the four groups. However, the CBT showed the greatest effect in the HAMD total score with the effect size=0.94, whereas the ST has only a moderate effect size in the WSAS total score (effect size=0.47). The findings support the feasibility and effectiveness of CBT as a psychosocial intervention for Chinese patients with moderate-severe MDD. We also found that single treatment using MED or CBT performed equally well as the combined CBT-antidepressant treatment in controlling the remission. The study provided important knowledge to inform the mental health care planning in China.
    Full-text · Article · Oct 2013 · Journal of Affective Disorders
    Si Zu Si Zu Yu-Tao Xiang Yu-Tao Xiang Jing Liu Jing Liu +9 more authors... Ling Zhang Ling Zhang
    0Comments 7Citations
    • "...ication both for seasonal and nonseasonal depression (Even et al., 2008; Lam et al., 2006; Rohan et al., 2009b). Cognitive behavioral therapy stands out for its promise in preventing recurrence of seasonal depr..."
      Valid methods of identifying seasonal depression will advance etiological studies, but may not affect treatment recommendations at this time, as there is evidence for the efficacy of cognitive behavioral therapy, light therapy, and antidepressant medication both for seasonal and nonseasonal depression (Even et al., 2008; Lam et al., 2006; Rohan et al., 2009b). Cognitive behavioral therapy stands out for its promise in preventing recurrence of seasonal depression and may be especially appropriate when patients' negative expectations about the effects of the seasons on their mood and behavior are significant.
    [Show abstract] [Hide abstract] ABSTRACT: There is evidence that seasonal variation in depressive symptoms is common in the population. However, research is limited by a reliance on longterm retrospective methods. Seasonal patterns were tested in two samples of community participants recruited in separate prospective studies in the Midwestern (n=556 males/females) and Pacific Northwestern (n=206 males) United States. Participants completed self-report measures of depressive symptoms 10-19 times from ages 14 to 36 years (n=8316 person observations). These data were compared with local meteorological conditions (e.g., solar radiation) recorded across the 2 weeks prior to each self-report. In within-subjects analyses, participants' depressive symptoms and the probability of clinically significant symptoms varied with the time of year, as hypothesized (highest in the weeks of early Winter; lowest in early Fall). However, effect sizes were modest and were not explained by recent sunlight or other meteorological conditions. Samples were not nationally representative. Participants did not complete retrospective reports of seasonal depression or measures of current vegetative symptoms. Neither time of the year nor recent seasonally linked meteorological conditions were powerful influences on depressive symptoms experienced by community populations in relevant geographic regions. Prior studies may have overestimated the prevalence and significance of seasonal variation in depressive symptoms for the general population.
    Full-text · Article · Aug 2013 · Journal of Affective Disorders
    0Comments 6Citations
    • "...e a targeted CBT for sleep to an existing CBT that has been specifically designed for SAD (Rohan et al., 2009 ). Similar interwoven treatments combining CBT for depression and insomnia are being tested (Harvey..."
      It is possible that sleep-related beliefs and other typical depressogenic beliefs have similar origins, although a recent study with individuals with depression and insomnia found that unhelpful beliefs about sleep did not improve with CBT for depression (Carney et al., 2011). If DBAS-16 scores are elevated during summer remission, it may be appropriate to interweave a targeted CBT for sleep to an existing CBT that has been specifically designed for SAD (Rohan et al., 2009 ). Similar interwoven treatments combining CBT for depression and insomnia are being tested (Harvey, 2011 ), and psychological treatments for hypersomnia are in development (Kaplan and Harvey, 2009).
    [Show abstract] [Hide abstract] ABSTRACT: BACKGROUND: Unhelpful sleep-related cognitions play an important role in insomnia and major depressive disorder, but their role in seasonal affective disorder has not yet been explored. Therefore, the purpose of this study was to determine if individuals with seasonal affective disorder (SAD) have sleep-related cognitions similar to those with primary insomnia, and those with insomnia related to comorbid nonseasonal depression. METHODS: Participants (n=147) completed the Dysfunctional Beliefs and Attitudes about Sleep 16-item scale (DBAS-16) and the Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorder Version (SIGH-SAD), which assesses self reported sleep problems including early, middle, or late insomnia, and hypersomnia in the previous week. All participants were assessed in winter, and during an episode for those with a depressive disorder. RESULTS: Individuals with SAD were more likely to report hypersomnia on the SIGH-SAD, as well as a combined presentation of hypersomnia and insomnia on the Pittsburgh Sleep Quality Index (PSQI). The SAD group reported DBAS-16 scores in the range associated with clinical sleep disturbance, and DBAS-16 scores were most strongly associated with reports of early insomnia, suggesting circadian misalignment. LIMITATIONS: Limitations include the self-report nature of the SIGH-SAD instrument on which insomnia and hypersomnia reports were based. CONCLUSIONS: Future work could employ sleep- or chronobiological-focused interventions to improve clinical response in SAD.
    Full-text · Article · May 2013 · Journal of Affective Disorders
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