Treatment Of Depression Collaborative Research Program Research Articles

Clinical effectiveness of cognitive behavioral therapy for depression in routine care: A propensity score based comparison between randomized controlled trials and clinical practice

BackgroundThe efficacy of cognitive behavioral therapy (CBT) for the treatment of depressive disorders has been demonstrated in many randomized controlled trials (RCTs). This study investigated whether for CBT similar effects can be expected under routine care conditions when the patients are comparable to those examined in RCTs. MethodN=574 CBT patients from an outpatient clinic were stepwise matched to the patients undergoing CBT in the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP). First, the exclusion criteria of the RCT were applied to the naturalistic sample of the outpatient clinic. Second, propensity score matching (PSM) was used to adjust the remaining naturalistic sample on the basis of baseline covariate distributions. Matched samples were then compared regarding treatment effects using effect sizes, average treatment effect on the treated (ATT) and recovery rates. ResultsCBT in the adjusted naturalistic subsample was as effective as in the RCT. However, treatments lasted significantly longer under routine care conditions. LimitationsThe samples included only a limited amount of common predictor variables and stemmed from different countries. There might be additional covariates, which could potentially further improve the matching between the samples. ConclusionsCBT for depression in clinical practice might be equally effective as manual-based treatments in RCTs when they are applied to comparable patients. The fact that similar effects under routine conditions were reached with more sessions, however, points to the potential to optimize treatments in clinical practice with respect to their efficiency.

Therapist responsiveness and patient engagement in therapy

This study tests the hypothesis that therapist responsiveness in the first two sessions of therapy relates to three measures of early patient engagement in treatment. Using videotapes and data from the NIMH Treatment of Depression Collaborative Research Program (TDCRP), an instrument was developed to measure therapist responsiveness in the first two sessions of Cognitive Behavior Therapy and Interpersonal Psychotherapy. A factor measuring positive therapeutic atmosphere, as well as a global item of therapist responsiveness, predicted both the patient's positive perception of the therapeutic relationship after the second session and the patient's remaining in therapy for more than four sessions. A negative therapist behavior factor also predicted early termination. Factors measuring therapist attentiveness and early empathic responding did not predict the engagement variables.

Social Class and Work Functioning in Treatment for Depression

Social Class and Work Functioning in Treatment for Depression

Editorial: Evaluating Interventions in Child Mental Health: The Importance of Care Provider and Contextual Influences

B R U C E WA M P O L D I N H I S B O O K The great psychotherapy debate, highlights the tension between a narrow, ‘medical’ model of evaluating psychological treatments and a broader evaluative framework which takes contextual factors into account, including the influence of the therapists themselves on treatment outcome (Wampold, 2001). Such ideas have fuelled an interesting debate in the field of psychological treatment research and a special section of the journal Psychotherapy Research was recently devoted to the topic of the extent to which therapist effects had a bearing on treatment outcome (Hill, 2006). Wampold’s main contention is that therapists account for a greater proportion of the variance in treatment outcome than any particular model of psychological intervention and hence greater attention should be paid to the attributes of effective therapists. One of the studies to be examined most in relation to this issue is the NIMH Treatment of Depression Collaborative Research Program (TDCRP) Multicentre Randomized Controlled Trial (RCT). This RCT compared the outcome of Cognitive Behaviour Therapy (CBT) vs. Interpersonal Psychotherapy (IPT) vs. Antidepressant medication vs. Placebo in adults with Major Depression. Minimal differences between different models of intervention were identified, and subsequent re-analyses of the data looking for therapist effects in the CBT and IPT arms came to conflicting conclusions. One analysis found significant therapist effects (Kim, Wampold, & Bolt, 2006) while another, using different statistical methods, found no effects (Elkin, Falconnier, Martinovich, & Mahony, 2006)! What is the relevance of all this to child mental health? Intuitively as practitioners many of us will hold the view that the qualities and skills of the person delivering a particular treatment and the setting in which the treatment is undertaken may be as important as the actual model of intervention itself. However, this issue has received little attention in the field of child mental health research. This is likely to change in future following the publication of the CONSORT guidance extension for RCTs of nonpharmacologic treatments (Boutron, Moher, Altman, Schulz, & Ravaud, 2008). CONSORT, or the Consolidated Standards of Reporting Trials, is the gold standard guidance by which RCTs are reported. Researchers generally undertake to conduct and report on trials according to CONSORT. The new guidance, published this year, emphasizes that in fields such as surgery or psychotherapy, where the intervention is generally complex and multi-dimensional and influenced by the skills and expertise of the ‘care provider’ as well as the setting in which the treatment is undertaken, care must

Patterns of early change and their relationship to outcome and follow-up among patients with major depressive disorders

Background While highlighting the efficacy of different treatments for major depressive disorders (MDD), findings of the National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program (TDCRP) often are interpreted as supporting the idea of treatment non-specificity for MDD. However, heterogeneity in treatment courses and outcomes might be undetected when focusing only on types of treatment in terms of sample means without taking into account early change in treatment. Method In this study, growth mixture models (GMM) were used in the completer sample of N = 162 patients from the NIMH TDCRP to identify meaningful patterns of early change of depression severity that are shared by many individual patients. Results Results revealed three typical patterns of early change over the first 8 weeks of treatment irrespective of the type of treatment protocol provided: (a) moderate to severe depression with moderate early improvement, (b) moderate to severe depression with rapid early improvement, and (c) mild to moderate depression with moderate early improvement. In contrast to the type of treatment, these differential patterns of early response (together with overall pre-treatment symptom severity) predicted outcomes (i.e. depression severity) at treatment termination and over the 1.5-year follow-up period. Limitations Due to the small sample size and the controlled setting of this study the degree to which these results can be generalized to clinical practice has to be further investigated. Conclusions The findings provide further support for the assumption that early change is an important factor for the prediction of short- and long-term outcome in psychotherapy.

Socioeconomic status in the treatment of depression.

This study examined outcomes and attrition across three treatments for depression in relation to socioeconomic status (SES). The study was based on data available from the Treatment of Depression Collaborative Research Program (TDCRP) of the National Institute of Mental Health (NIMH; Elkin, 1994), a multisite collaborative study that examined the effectiveness of two forms of psychotherapy, cognitive behavior therapy and interpersonal psychotherapy, and pharmacotherapy. Results indicated that lower SES, measured by the Hollingshead Index of Social Position, was associated with less improvement across all three treatments for depression. The effect of SES on outcome did not differ by treatment modality. Contrary to expectations, SES was not associated with attrition. These findings suggest that there may be limitations in the use of these empirically validated treatments with lower SES depressed patients, as their improvement rates may be less than those of middle SES depressed patients treated by the same modalities. The results of this study also suggest that a standardized measure of SES may be more sensitive to SES differences in outcome than the more easily obtained measures of education or income. Suggestions are provided for additional research in this area to address the potential mediators and moderators of the association between SES and outcome.

Therapist effects: Clever ways to make them (and everything else) disappear

The purpose of Kim, Wampold, and Bolt's (2005) analysis of the National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program (TDCRP) data was to estimate the pro...

Psychiatrist effects in the psychopharmacological treatment of depression

Background The National Institutes of Mental Health's (NIMH) 1985 Treatment of Depression Collaborative Research Program (TDCRP) reported that imipramine hydrochloride with clinical management (IMI-CM) was significantly more beneficial than placebo with clinical management (PLA-CM) for individuals undergoing treatment for depression. Unfortunately, in analyzing the NIMH TDCRP data, researchers ignored the potential effect that psychiatrists have on patient outcomes, thereby assuming that psychiatrists are equally effective. However, this assumption has yet to be supported empirically. Therefore, the purpose of the current study is to examine psychiatrist effects in the NIMH TDCRP study and to compare the variation among psychiatrists to the variation between treatments. Method Data from 112 patients [IMI-CM ( n = 57, 9 psychiatrists); PLA-CM ( n = 55, 9 psychiatrists)] from the NIMH TDCRP study were reanalyzed using a multi-level model. Results The proportion of variance in the BDI scores due to medication was 3.4% ( p < .05), while the proportion of variance in BDI scores due to psychiatrists was 9.1% ( p < .05). The proportion of variance in the HAM-D scores due to medication was 5.9% ( p < .05), while the proportion of variance in HAM-D scores due to psychiatrist was 6.7% ( p = .053). Therefore, the psychiatrist effects were greater than the treatment effects. Conclusions In this study, both psychiatrists and treatments contributed to outcomes in the treatment of depression. However, given that psychiatrists were responsible for more of the variance in outcomes it can be concluded that effective treatment psychiatrists can, in fact, augment the effects of the active ingredients of anti-depressant medication as well as placebo.

Empirical evaluation of the assumptions in identifying evidence based treatments in mental health

Extensive analyses of data from the remarkably comprehensive data set established by the Treatment of Depression Collaborative Research Program (TDCRP), initiated and conducted by the National Institute of Mental Health (NIMH), enabled us to examine the contributions of three dimensions of the treatment process (type of treatment, aspects of the therapeutic relationship, and patients' pretreatment personality characteristics) to three assessments of therapeutic change (symptom reduction, reduction of vulnerability, and development of adaptive capacities) evaluated at termination and extended follow-up. The most consistent factors predicting therapeutic gain were the quality of the therapeutic relationship and patients' pretreatment personality dimensions. The implications of these findings for clinical practice, training, and research are discussed.

Role of perfectionism and personality disorder features in response to brief treatment for depression.

Using data from the Treatment of Depression Collaborative Research Program (TDCRP), the authors compared the role of patients' perfectionism and features of personality disorder (PD) in the outcome of brief treatment for depression. Data were extracted as to patients' intake levels of symptoms; perfectionism; and PD features, measured as continuous variables, as well as their symptoms at termination; their contribution to the therapeutic alliance; and their satisfaction with social relations. Poorer therapeutic outcome was demonstrated for patients with elevated levels of perfectionism and odd-eccentric and depressive PD features. Patients' contribution to therapeutic alliance and satisfaction with social relations were predicted by perfectionism but not by PD features. Results highlight the central role played by patients' personality in the course of brief treatment for depression.

Predictors of persistent social impairment among recovered depressed outpatients

Background: Though the social functioning of most depressed outpatients improves with effective treatment, a subgroup may remain impaired after recovering from depression. The purpose of this study was to identify predictors of residual social impairment among patients who recovered from depression. Methods: These data were obtained from the Treatment of Depression Collaborative Research Program (TDCPR) public access tape. The TDCPR tested the relative efficacy of two psychotehrapies, imipramine, and placebo in major depression. Patients received follow-up assessments after completing the clinical trial. The following assessment instruments were used to assess predictor variables: Social Adjustment Scale II, Personality Assessment Form (PAF), Longitudinal Interval Follow-up Events (LIFE), and the Schedule for Affective Disorders (SADS). Results: Recovered patients who were socially impaired at the end of treatment and six months later, had a higher rate of Intermittent Depression, and reported greater malfunctioning during adolescence than recovered patients whose functioning was unimpaired after treatment and at follow-up. The rates of personality disorders were not significantly different between these groups. Limitations: These analyses were performed post-hoc and the sample size was small. Conclusions: A chronic course of depression predicted persistent social maladjustment among patients who recovered from depression for 6 months.

When and how perfectionism impedes the brief treatment of depression: Further analyses of the National Institute of Mental Health Treatment of Depression Collaborative Research Program.

Perfectionism has previously been identified as having a significant negative impact on therapeutic outcome at termination in the brief (16-week) treatment of depression (S. J. Blatt, D. M. Quinlan, P. A. Pilkonis, & T. Shea, 1995) as measured by the 5 primary outcome measures used in the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP). The present analyses of other data from the TDCRP indicated that this impact of perfectionism on therapeutic outcome was also found in ratings by therapists, independent clinical evaluators, and the patients and that this effect persisted 18 months after termination. In addition, analyses of comprehensive, independent assessments made during the treatment process indicated that perfectionism began to impede therapeutic gain in approximately 2/3 of the sample, in the latter half of treatment, between the 9th and 12th sessions. Implications of these findings are discussed, including the possibility that more perfectionistic patients may be negatively impacted by anticipation of an arbitrary, externally imposed termination date.

The efficacy of imipramine and psychotherapy in early-onset chronic depression: a reanalysis of the National Institute of Mental Health Treatment of Depression Collaborative Research Program

The authors compared the effectiveness of Cognitive Behavioral Therapy (CBT), Interpersonal Psychotherapy (IPT), Imipramine Clinical Management (ICM) to Placebo Clinical Management (PCM) for outpatients with early-onset chronic depression ( N=65) in the National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program (TDRP). The post-treatment depression scores of the CBT, IPT, and ICM groups were not significantly different from the PCM group. We did not find a relationship between the duration of Major Depression and response to a specific treatment. Studies are needed to determine if combining psychotherapy with medication improves social functioning and enhances the quality of life for patients with chronic depression.

Science is not a trial (but it can sometimes be a tribulation).

This article addresses a few of the most important issues raised by N. S. Jacobson and S. D. Hollon and by D. F. Klein about the findings of the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP). Questions addressed include the following: (a) What was the relative effectiveness of the treatments in the TDCRP for patients with severe depressive symptomatology? (b) Were there Treatment × Research Site interactions within the more severely depressed subsamples? (c) Was there adequate implementation of cognitive—behavior therapy (CBT) and other treatment conditions in the TDCRP? and (d) How do the relapse rates in the TDCRP compare with those in other studies? Current conclusions regarding all of these issues are presented. For the future, it is recommended that, rather than revisiting these issues again, researchers apply their energies to investigating new questions using the valuable TDCRP database.

The destructiveness of perfectionism. Implications for the treatment of depression.

Reports in the public media indicate that intense perfectionism and severe self-criticism played a role in the suicide of three remarkably talented individuals. The role of perfectionism in these suicides is consistent with recent extensive investigations of aspects of perfectionism as well as further analyses of the NIMH Treatment of Depression Collaborative Research Program (TDCRP), indicating that intense perfectionism interfered significantly with therapeutic response in the various brief treatments for depression. Self-critical individuals, however, made substantial improvement in long-term intensive treatment. These findings suggest the value of considering psychopathology, especially depression, from a psychological rather than a symptomatic perspective; that different patients may be differentially responsive to various types of therapy; and that more extensive therapy may be necessary for many highly perfectionistic, self-critical patients.

Applying the Collaborative Study Psychotherapy Rating Scale to rate therapist adherence in cognitive-behavior therapy, interpersonal therapy, and clinical management.

Adherence of therapists to behaviors specified in cognitive-behavior therapy, interpersonal therapy, and clinical management manuals was studied. Raters used the Collaborative Study Psychotherapy Rating Scale (CSPRS) to rate therapist adherence in each of four sessions from 180 patients in the treatment phase of the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP). Results indicate that therapists exhibited more behaviors appropriate to their own respective treatment approaches than to other treatment approaches. In fact, the three treatments could be discriminated almost perfectly using the CSPRS. Analysis of the psychometric properties of the CSPRS revealed high interrater reliability and high internal consistency. However, a five-component structure extracted from the intercorrelations of the CSPRS items was substantially different from a five-factor structure found in an earlier study.

Mode-specific effects among three treatments for depression.

In the NIMH Treatment of Depression Collaborative Research Program (TDCRP), 250 depressed outpatients were randomly assigned to interpersonal psychotherapy, cognitive-behavioral therapy, imipramine plus clinical management, or pill placebo plus clinical management treatments. Although all treatments demonstrated significant symptom reduction with few differences in general outcomes, an important question concerned possible effects specific to each treatment. The therapies differ in rationale and procedures, suggesting that mode-specific effects may differ among treatments, each of which was precisely specified, applied appropriately, and shown to be discriminable. Outcome measures were selected for presumed sensitivity to the different treatments. Findings provided only scattered and relatively insubstantial support for mode-specific differences. None of the therapies produced consistent effects on measures related to its theoretical origins.