Trials Of Psychological Interventions Research Articles

Editorial: Journal of Pediatric Psychology—Statement of Purpose Section on Randomized Trials

The future of our profession depends considerably on the extent to which we are able to design and conduct carefully conceived clinical trials of interventions targeting important clinical problems in pediatric psychology and on the effectiveness of our communication and dissemination of those results. Within the past few years, the Journal of Pediatric Psychology has made several appeals to its readership and put forth a variety of efforts to encourage the publication of randomized controlled trials of psychological interventions conducted in the context of pediatric health care and to enhance the broader impact of those publications. A 2003 issue of the journal included two papers (McGarth, Stinson, & Davidson, 2003; Stinson, McGrath, & Yamada, 2003) and an editorial (Brown, 2003) on the merits of applying the Consolidated Standards for Reporting Clinical Trials (CONSORT) criteria (Begg et al., 1996; Rennie, 2001) to treatment outcome studies reported in the journal. A subsequent 2005 special issue of the journal was dedicated to family-based interventions in pediatric psychology and this included reports of treatment outcome studies targeting varied clinical problems (Browne & Talmi, 2005; Ellis, Naar-King, Frey, Templin, Rowland, & Cakan, 2005; Kazak et al., 2005; Lobato & Kao, 2005). Most recently, Drotar (2005a,b) communicated the journal’s intent to encourage the publication of papers reporting the results of intervention trials, papers illustrating or elucidating methodological, logistical, analytic, or ethical issues that pertain to treatment outcome studies and discussion of theoretical issues that may stimulate the development of clinical trials in pediatric psychology. A special section of the journal for treatment outcome papers was created. These efforts to stimulate articles reporting the results of randomized controlled trials have borne fruit. The journal has recently published quite a few examples of papers that report carefully conducted randomized controlled trials of psychological interventions applied to problems appearing in pediatric health-care contexts. Dr Drotar has renewed this commitment and assigned me, as a new Associate Editor, the responsibility for coordinating the reviews of manuscripts that report the results of randomized controlled trials. Through this statement of purpose, I hope to make myself busier in that role, but also to make my editorial quality of life somewhat more enjoyable and gratifying. In that spirit, I will offer the following suggestions to those planning future intervention trials and to those considering the submission of manuscripts reporting randomized trial results to the Journal of Pediatric Psychology.

Empirically supported psychological interventions for social phobia in adults: a qualitative review of randomized controlled trials

Social phobia is a chronic disorder that results in substantial impairment. We conducted a qualitative review of randomized controlled trials (RCTs) of psychological interventions for social phobia. Articles were identified through searches of electronic databases and manual searches of reference lists. They were classified by psychological interventions evaluated. Data regarding treatment, participants and results were then extracted and tabulated. We identified which psychological interventions are empirically supported, using the scheme proposed by Chambless & Hollon (Journal of Consulting and Clinical Psychology 1998, 66, 7-18). Thirty studies evaluating the efficacy of social skills training (SST), exposure therapy and/or cognitive treatments were identified. Cognitive behavior therapy (CBT), involving cognitive restructuring and exposure to feared and avoided social situations or behavioral experiments, was found to be an efficacious and specific treatment for social phobia. Exposure therapy was found to be an efficacious treatment since most of the evidence of its efficacy was from comparisons with no treatment. There were mixed findings regarding the relative efficacy of CBT and in vivo exposure. Some studies reported that the interventions were equivalent, while others found that patients treated with CBT had a better outcome. There was little evidence to support the use of SST. CBT is the psychological intervention of choice for social phobia. The findings of this review are compared to those of other major reviews and limitations are discussed.

Psychosocial and psychological interventions for treating antenatal depression

Although pregnancy was once thought of as a time of emotional wellbeing for many women, conferring 'protection' against psychiatric disorders, a recent meta-analysis of 21 studies suggests the mean prevalence rate for depression across the antenatal period is 10.7%, ranging from 7.4% in the first trimester to a high of 12.8% in the second trimester. Due to maternal treatment preferences and potential concerns about fetal and infant health outcomes, non-pharmacological treatment options are needed. The primary objective of this review is to assess the effects, on mothers and their families, of psychosocial and psychological interventions compared with usual antepartum care in the treatment of antenatal depression. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2006), the Cochrane Collaboration Depression Anxiety and Neurosis Group's Trials Registers (CCDANCTR-Studies and CCDANCTR-References) (July 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 3), MEDLINE (1966 to July 2006), EMBASE (1980 to July 2006) and CINAHL (1982 to July 2006). We also scanned secondary references and contacted experts in the field to identify other published or unpublished trials. All published, unpublished and ongoing randomised controlled trials of preventive psychosocial or psychological interventions in which the primary or secondary aim is to treat antenatal depression. We excluded quasi-randomised trials (for example, those randomised by delivery date, or odd versus even medical record numbers) from the analysis. All review authors participated in the evaluation of methodological quality and data extraction. Results are presented using relative risk for categorical data and weighted mean difference for continuous data. One US trial was included in this review, incorporating 38 outpatient antenatal women who met Diagnostic and Statistical Manual for Mental Disorders-IV criteria for major depression. Interpersonal psychotherapy, compared to a parenting education program, was associated with a reduction in the risk of depressive symptomatology immediately post-treatment using the Clinical Global Impression Scale (one trial, n = 38; relative risk (RR) 0.46, 95% confidence interval (CI) 0.26 to 0.83) and the Hamilton Rating Scale for Depression (one trial, n = 38; RR 0.82, 95% CI 0.65 to 1.03). The evidence is inconclusive to allow us to make any recommendations for interpersonal psychotherapy for the treatment of antenatal depression. The one trial included was too small, with a non-generalisable sample, to make any recommendations.

Psychological treatment for anxiety in people with traumatic brain injury

Psychological treatments are commonly used in the management of anxiety. Certain types of psychological treatments are well suited to needs of people with traumatic brain injury (TBI). We have systematically reviewed studies examining the effectiveness of these approaches for TBI. To assess the effects of psychological treatments for anxiety in people with TBI. We searched the following databases up until March 2006: Cochrane Injuries Group's specialised register, Cochrane Depression, Anxiety and Neurosis Group's specialised register, Cochrane Central Register of Controlled Trials, MEDLINE, PsycINFO, EMBASE, CINAHL, AMED, ERIC, and PsycBITE. Additionally, key journals were handsearched and reference lists of included trials were examined to identify further studies meeting inclusion criteria. Randomised controlled trials of psychological treatments for anxiety, with or without pharmacological treatment, for people with TBI were included in the review. Pharmacological treatments for anxiety in isolation (without psychological intervention) were excluded. Two authors independently assessed methodological quality and extracted data from the included trials. Three trials were identified in this review as satisfying inclusion criteria. Results of all three trials were evaluated, however, one of these trials had compromised methodological quality and, therefore the focus was placed on the other two trials. Data were not pooled due to the heterogeneity between trials. The first trial (n = 24) showed a benefit of cognitive behavioural therapy (CBT) in people with mild TBI and acute stress disorder. Fewer people receiving CBT had diagnosis of post-traumatic stress disorder (PTSD) at post-treatment compared to the control supportive counselling group, with maintenance of treatment gains found at six-month follow up. The second trial (n = 20) showed that post-treatment anxiety symptomatology of people with mild to moderate TBI was lower in the combined CBT and neurorehabilitation group compared to the no intervention control group. This review provides some evidence for the effectiveness of CBT for treatment of acute stress disorder following mild TBI and CBT combined with neurorehabilitation for targeting general anxiety symptomatology in people with mild to moderate TBI. These findings need to be viewed in light of the small number, small sample size and heterogeneous characteristics of current trials published in this area. More trials focusing on comparable psychological interventions, severity of injury of participants and diagnosis of anxiety disorder(s) are needed.

Cognitive behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigor.

Background: Guidance in the United States and United Kingdom has included cognitive behavior therapy for psychosis (CBTp) as a preferred therapy. But recent advances have widened the CBTp targets to other symptoms and have different methods of provision, eg, in groups. Aim: To explore the effect sizes of current CBTp trials including targeted and nontargeted symptoms, modes of action, and effect of methodological rigor. Method: Thirty-four CBTp trials with data in the public domain were used as source data for a meta-analysis and investigation of the effects of trial methodology using the Clinical Trial Assessment Measure (CTAM). Results: There were overall beneficial effects for the target symptom (33 studies; effect size = 0.400 [95% confidence interval {CI} = 0.252, 0.548]) as well as significant effects for positive symptoms (32 studies), negative symptoms (23 studies), functioning (15 studies), mood (13 studies), and social anxiety (2 studies) with effects ranging from 0.35 to 0.44. However, there was no effect on hopelessness. Improvements in one domain were correlated with improvements in others. Trials in which raters were aware of group allocation had an inflated effect size of approximately 50%–100%. But rigorous CBTp studies showed benefit (estimated effect size = 0.223; 95% CI = 0.017, 0.428) although the lower end of the CI should be noted. Secondary outcomes (eg, negative symptoms) were also affected such that in the group of methodologically adequate studies the effect sizes were not significant. Conclusions: As in other meta-analyses, CBTp had beneficial effect on positive symptoms. However, psychological treatment trials that make no attempt to mask the group allocation are likely to have inflated effect sizes. Evidence considered for psychological treatment guidance should take into account specific methodological detail.

Attempting to prevent depression in youth: a systematic review of the evidence

AbstractAim: The aim of this review was to update the information on prevention and early intervention programmes for depression in adolescents.Method: We searched the literature to the end of July 2006 for published randomized controlled trials of psychological interventions specifically designed to prevent the onset of depression among children and adolescents (aged 5 to 19 years) who did not already meet the criteria for a clinical diagnosis of depressive illness.Results: Findings have been mixed. Positive results after intervention and at follow‐up have been reported in a number of targeted studies, although an attempt to replicate findings in a school and in a primary care setting were unsuccessful. Most studies of universal interventions have shown a short‐term effect that did not persist at follow‐up. There are a number of methodological problems with studies to date. Issues that have not been addressed include taking into account the placebo effect, measuring the incidence of depressive disorder following intervention and ensuring the quality and fidelity of intervention is adequate. Interventions to date may have been too short to create durable change.Conclusions: There is no clear evidence to date that depression prevention is effective and implementation of depression prevention programmes would be premature on current evidence. However, given the positive finding in some studies, and the cost of depressive disorder, further research is warranted. Attempts to reduce depressive disorder in the community should address wider social issues, as well as improving on the narrower interventions focusing on individual protective and risk factors.

Randomized controlled clinical trials of psychological interventions to improve glycemic control in pediatric and adult patients with T1DM

Randomized controlled clinical trials of psychological interventions to improve glycemic control in pediatric and adult patients with T1DM

The Effects of Psychological Intervention on Atopic Dermatitis

Background: Psychological interventions may be valuable in atopic dermatitis. We systematically reviewed and carried out a meta-analysis of randomized controlled trials of psychological interventions. Methods: Electronic searches and manual journal searches were carried out. Two coders independently coded study designs, participants, treatments and outcome characteristics of the studies meeting the selection criteria. Results: Eight journal articles published between 1986 and 2006 were included. Eight types of intervention were tested: aromatherapy, autogenic training, brief dynamic psychotherapy, cognitive-behavioral therapy, dermatological education and cognitive-behavioral therapy, habit reversal behavioral therapy, a stress management program, and structured educational programs. Effect sizes were computed as correlation coefficient (r), and random effects models were used in the analysis. For eczema severity, the average effect size for the 8 trials including 8 interventions was –0.367 [χ²(1) = 7.452, p = 0.006; 95% CI –0.579 to –0.108]. The average effect sizes on itching intensity (5 trials with 5 interventions) and scratching (5 trials with 4 interventions) were –0.805 [χ²(1) = 4.719, p = 0.030; 95% CI –0.971 to –0.108] and –0.620 [χ²(1) = 24.24, p < 0.0001; 95% CI –0.767 to –0.410], respectively. Conclusions: Although the present meta-analysis revealed that psychological interventions had a significant ameliorating effect on eczema severity, itching intensity and scratching in atopic dermatitis patients, a definite conclusion about their effectiveness seems premature. Accordingly, future studies should involve more sophisticated methodologies, use established measures of outcome variables, adjust for possible confounders between the intervention and control groups, and provide sufficient data to calculate the effect sizes for future meta-analyses.

Psychological treatments versus treatment as usual for obsessive compulsive disorder (OCD)

Obsessive compulsive disorder (OCD) is a chronic anxiety disorder associated with significant morbidity, social impairment and lower quality of life. Psychological treatments are a frequently used approach for OCD. To perform a systematic review of randomised trials of psychological treatments for obsessive compulsive disorder in comparison with treatment as usual. We conducted an electronic search of CCDANCTR-Studies (31/10/2006), and other databases. We searched reference lists, and contacted experts in the field. Published and unpublished randomised trials of psychological treatments versus treatment as usual for adults with a diagnosis of OCD DATA COLLECTION AND ANALYSIS: Two review authors worked independently throughout the selection of trials and data extraction. Findings were compared and disagreements were discussed with a third review author. Full data extraction, using a standardised data extraction sheet, was performed on all studies included in the review. Results were synthesised using Review Manager software. For dichotomous data, odds ratios were calculated. For continuous data, effect sizes were obtained and the standardised mean difference, with 95% confidence intervals, was calculated. Fixed and random effects models were used to pool the data. Reasons for heterogeneity in studies were explored and sensitivity analyses were performed by excluding trials of lower quality. Eight studies (11 study comparisons) were identified, all of which compared cognitive and/or behavioural treatments versus treatment as usual control groups. Seven studies (ten comparisons) had usable data for meta-analyses. These studies demonstrated that patients receiving any variant of cognitive behavioural treatment exhibited significantly fewer symptoms post-treatment than those receiving treatment as usual (SMD -1.24, 95% CI -1.61 to -0.87, I(2) test for heterogeneity 33.4%). Different types of cognitive and/or behavioural treatments showed similar differences in effect when compared with treatment as usual. The overall treatment effect appeared to be influenced by differences in baseline severity. The findings of this review suggest that psychological treatments derived from cognitive behavioural models are an effective treatment for adult patients with obsessive compulsive disorder. Larger high quality randomised controlled trials involving longer follow up periods are needed, to further test cognitive behavioural treatments, and other psychological approaches, in comparison to each other and control conditions. Future trials should examine the predictors of response to each treatment, and also conduct cost-effectiveness evaluations.

Bipolar disorder: What can psychotherapists learn from the cognitive research?

Randomized controlled trials of psychological treatment, principally cognitive therapy, for bipolar disorder have yielded inconsistent results. Given the status of this evidentiary base, we provide a more fine-grained analysis of the cognitive profiles associated with bipolar disorder to inform clinical practice. In this practice-friendly review, we consider evidence that both negative and positive cognitive styles are related to bipolar disorder. Cross-sectional and prospective evidence suggest that negative cognitive styles are related to depression within bipolar disorder, but there also is evidence that bipolar disorder is related to an elevated focus on goals as well as to increases in confidence during manic states. With such findings as backdrop, we consider the outcomes of psychological treatments for bipolar disorder and advance several suggestions for clinical practice.

IO2-6 The Ponder Trial : A Cost-effectiveness Trial of Psychological Intervention by Health Visitors for Postnatal Depression(ISPOG2007)

IO2-6 The Ponder Trial : A Cost-effectiveness Trial of Psychological Intervention by Health Visitors for Postnatal Depression(ISPOG2007)

Can Psychological Interventions Improve Glycemic Control in Type 1 Diabetes

Although diabetes is associated with various psychological problems, data on the effectiveness of psychological interventions in improving glycemic control are limited. British investigators performed this systematic review and meta-analysis of randomized trials of psychological interventions in children (16 studies) and …

A randomized controlled trial of psychological interventions for postnatal depression

First, to establish the efficacy of psychological interventions versus routine primary care for the management of postnatal depression (PND). Secondly, to provide a direct comparison of cognitive-behavioural therapy (CBT) versus counselling and, finally, to compare the relative value of group and individual delivery formats. The study involved 192 depressed women drawn from a large community screening programme in Melbourne, Australia and allocated to cognitive behaviour therapy, counselling, or routine primary care. Baseline and post-intervention measures of depression and anxiety were collected in the form of validated self-report inventories. Women were screened in the community and diagnosis of depression confirmed with a standardized psychiatric interview. Interventions were of 12 weeks duration, including three partner sessions, and adhered to a structured manual. Psychological intervention per se was superior to routine care in terms of reductions in both depression and anxiety following intervention. For those women with PND, psychological intervention is a better option than routine care, leading to clinically significant reduction of symptoms. Counselling may be as effective as group cognitive behaviour therapy. The benefits of psychological intervention may be maximized by being delivered on a one-to-one basis.

IN THIS ISSUE

This issue features groups of papers on depression in later life, controlled trials of psychological interventions, and chronic fatigue, together with additional papers.

The prevention of postnatal depression: A narrative systematic review

This systematic review assessed the success of randomized controlled trials of preventative interventions for postnatal depression (PND). Outcomes examined were estimates of PND prevalence. Methodological quality was determined through the examination of key components individually with independent data extraction by all three authors. Data sources included Medline, PsycINFO, Sociofile, CINAHL, COPAC, EMBASE, Cochrane library; hand searches and a newsletter requests for unpublished trials to the Marcé Society and Postpartum Support International. Twenty-one RCTs were included in this review. Nine of these trials demonstrated short-term preventative success (seven psychological and supportive interventions, one unpublished antidepressant trial and a calcium carbonate trial) but none provided any evidence of long-term success. Furthermore, the results of three of the psychological intervention trials should be viewed with caution due to a lack of methodological rigour. There is a need for future research into the prevention of PND to be tightly designed and maybe include an exploration of the experience of postnatal depression for multiparous women.

Integrating non-drug treatments in early schizophrenia

There is a range of psychological interventions for established schizophrenia. These include family interventions, motivational interventions for substance misuse and for non-adherence to medication, cognitive remediation for neurocognitive deficits and cognitive-behavioural therapy for symptoms. Psychological interventions may explicitly target risk factors for poor outcome, such as substance use, or protective factors, such as adherence to medication, or be directed at specific symptoms or deficits. There is emerging evidence for efficacy of psychological treatments during, following and even prior to the first episode. Important areas for further study are how different treatment modalities can interact productively, and patient and carer preferences for treatment. Many trials of psychological treatments have design flaws and this tends to overestimate the treatment effect.

How and for Whom? Asking Questions About the Utility of Psychosocial Interventions for Individuals Diagnosed With Cancer

A recent review revealed 155 randomized controlled trials of psychological interventions for cancer patients published through 1998, and many additional trials have been published since that time. Even a quick examination of the literature on the effects of psychosocial interventions on outcomes related to quality of life, such as psychological adjustment and fatigue in cancer patients, reveals that some randomized controlled trials are impressive in their positive outcomes, some produce mixed results, and some yield null findings. In recent qualitative and quantitative meta-analytic reviews of the relevant body of intervention research, the reviewers draw disparate conclusions, suggesting that the existing evidence demonstrates the utility of psychological interventions, yields a mixed picture, or supports no strong recommendations for their effectiveness. Just as the intervention studies included within the reviews differ dramatically on a number of dimensions, so do the reviews themselves on such factors as criteria for inclusion, outcomes examined, and approaches to the data. In this issue of the Journal of Clinical Oncology, Chan et al provide an example of a randomized controlled trial that yielded negative effects. Rather than continuing to ask the omnibus question of whether psychological interventions are effective for cancer patients and chalking up the trial by Chan et al as one for the “loss” column, posing questions that address the issues of how and for whom specific interventions do or do not carry positive effects might better illuminate directions for this important domain of psychosocial oncology. Asking how an intervention produces its effects involves an exploration of mechanisms or explanations for a trial’s findings. Characterizing the pathways through which an intervention produces positive effects can shed light on how the intervention might be refined further, and how seemingly distinct treatments might produce similar effects through common mechanisms. Asking how an intervention might have yielded disappointing findings also can be revealing, both in providing information on how much weight should be accorded to the findings and in helping researchers learn which paths not to pursue in developing interventions in the future. For both positive and negative trials, explanations for results are likely to lie in such factors as the nature of the sample studied, the intervention implemented, and the outcomes examined. For example, Chan et al acknowledge the high baseline functioning of the patient sample as a potential explanation for the lack of significant effects. If a sample of cancer patients reports low distress and otherwise high functioning at the outset of a trial, then it is statistically impossible for a significant intervention effect to emerge on those outcomes, at least without a very large sample. A related issue, particularly for trials that target patients during or shortly after medical treatment, is that many individuals tend to recover over time without psychological intervention, as also occurred in the trial by Chan et al, again working against the likelihood of detecting significant intervention effects over a standard care control. With regard to the nature of the intervention, it is important to note that the intervention by Chan et al was multimodal, encompassing such multiple core components as psychoeducation, supportive care, stress management, relaxation, and pain management. Furthermore, the intervention was individually tailored to each participant, with the specific content left to the discretion of the treating psychologist. Although many published psychological interventions also are multimodal and some include individual tailoring, the reader is left with a number of questions JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 23 NUMBER 22 AUGUST 1 2005

Interventions for treating chronic pelvic pain in women.

Chronic pelvic pain is common in women in the reproductive age group and it causes disability and distress and results in significant costs to health services. The pathogenesis of chronic pelvic pain is poorly understood. Often, investigation by laparoscopy reveals no obvious cause for pain. There are several possible explanations for chronic pelvic pain including undetected irritable bowel syndrome, the vascular hypothesis where pain is thought to arise from dilated pelvic veins in which blood flow is markedly reduced and altered spinal cord and brain processing of stimuli in women with chronic pelvic pain. As the pathophysiology of chronic pelvic pain is not well understood, its treatment is often unsatisfactory and limited to symptom relief. Currently, the main approaches to treatment include counseling or psychotherapy, attempting to provide reassurance using laparoscopy to exclude serious pathology, progestogen therapy such as medroxyprogesterone acetate, and surgery to interrupt nerve pathways. We aimed to identify and review treatments for chronic pelvic pain in women in the reproductive years. The review included studies of patients with a diagnosis of pelvic congestion syndrome or adhesions but excluded those with pain known to be caused by i) endometriosis, ii) primary dysmenorrhoea (period pain), iii) pain due to active chronic pelvic inflammatory disease, or iv) irritable bowel syndrome. The search strategy adopted by the Cochrane Menstrual Disorders and Subfertility Group was used. Randomised controlled trials (RCTs) with women who had chronic pelvic pain, excluding endometriosis, primary dysmenorrhoea, pain due to chronic pelvic inflammatory disease, or irritable bowel syndrome. The reviewers were prepared to consider studies of any intervention including lifestyle, physical, medical, surgical and psychological treatments. Outcome measures were pain rating scales, quality of life measures, economic analyses and adverse events. For each included trial, information was collected regarding the method of randomisation, allocation concealment, blinding, whether an intention to treat analysis could possibly be performed and relevant interventions and outcomes (see previous sections). Data were extracted independently by the two reviewers, using forms designed according to the Cochrane guidelines. Nine studies were identified of which five were of good methodological quality. Two studies were reported in a brief abstract only and were excluded. Progestogen (Medroxyprogesterone acetate) was associated with a reduction of pain during treatment. Counselling supported by ultrasound scanning was associated with reduced pain and improvement in mood. A multidisciplinary approach was beneficial for some outcome measures. Adhesiolysis was not associated with an improved outcome apart from where adhesions were severe. Sertraline was not beneficial. Further studies to confirm these observations are needed, together with full reporting of those studies which have been undertaken. Given the prevalence and health care costs associated with chronic pelvic pain in women, randomised controlled trials of other medical, surgical and psychological interventions are urgently required.

Early detection of schizophrenia

This article will evaluate the rationale and feasibility of detecting psychosis and schizophrenia earlier than is currently the case. Schizophrenia incidence may vary more than has been believed previously. Early detection studies fall into two groups. Firstly, operational criteria now exist for prodromal or at risk mental states which predict transition to psychosis of 20-40% over 1 year. The first randomized trials of antipsychotic drug and psychological interventions aimed at reducing this transition rate have shown promising results. Secondly, duration of untreated psychosis in the first episode seems genuinely to be associated with clinical outcome but how much of the association is truly causal remains disputed. Shortening duration of untreated psychosis by early detection of full psychosis appears feasible but its benefits are not yet unequivocally demonstrated.

Multimodal Therapy of Treatment Resistant Depression: A Study and Analysis

To demonstrate through the use of a case study, the application of cognitive psychotherapy in the treatment of resistant depression. The case of a woman with an 18-month history of resistant depression associated with low self-esteem, guilt and shame, who failed to respond to three therapeutic trials of anti-depressants is described. A detailed description of a CBT intervention over 12 sessions is given. Clear improvements on assessments of mood and hopelessness, along with overall improvements in social and occupational functioning were noted. These improvements were attributed to a combination of CBT and pharmacotherapy, where pharmacotherapy alone failed to alleviate symptoms. A concise literature review revealed relatively few published trials of psychological treatments, and a lack of clear guidelines on pharmacological treatments. More research is needed to explore the efficacy of psychological therapies for treatment resistant depression.