Ingo Zobel

Cognitive behavioral analysis system of psychotherapy versus interpersonal psychotherapy for early-onset chronic depression: A randomized pilot study

BACKGROUND The only psychotherapy specifically designed and evaluated for the treatment of chronic depression, the Cognitive Behavioral Analysis System of Psychotherapy (CBASP), has never been directly compared to another depression-specific psychological method. METHODS Thirty patients with early-onset chronic depression were randomized to 22 sessions of CBASP or Interpersonal Psychotherapy (IPT) provided in 16 weeks. Primary outcome was the score on the 24-item Hamilton Rating Scale for Depression (HRSD) assessed posttreatment by an independent blinded evaluator. Secondary endpoints were, among others, remission (HRSD≤8) rates and the Beck Depression Inventory (BDI). The study included a prospective naturalistic 12-month follow-up. RESULTS Intent-to-treat analyses of covariance (ANCOVA) revealed that there was no significant difference in posttreatment HRSD scores between the CBASP and the IPT condition, but in self-rated BDI scores. We found significantly higher remission rates in the CBASP (57%) as compared to the IPT (20%) group. One year posttreatment, no significant differences were found in the self-reported symptom level (BDI) using ANCOVA. LIMITATIONS The study used only a small sample size and no placebo control. The generalizability of the results may be limited to patients with a preference for psychological treatment. CONCLUSIONS While the primary outcome was not significant, secondary measures showed relevant benefits of CBASP over IPT. We found preliminary evidence that in early-onset chronic depression, an approach specifically designed for this patient population was superior to a method originally developed for the treatment of acute depressive episodes. Long-term results suggest that chronically depressed patients may need extended treatment courses.

Feasibility and Outcome of Cognitive Behavioral Analysis System of Psychotherapy (CBASP) for Chronically Depressed Inpatients: A Pilot Study

Patients received optimized pharmacotherapy in addition to the CBASP program in compliance with current national and international guidelines for depression treatment [13, 14] and according to clinical expert supervision ( table 1 ). Ten inpatients with severe chronic depression according to DSM-IV were included in this pilot study. Exclusion criteria were limited to a history of bipolar I disorder, comorbid substance dependence with less than 3 months of abstinence, and mental disorders due to organic factors. The SCID I and II [15, 16] were used for diagnosis. Early trauma and life events were assessed by using the Childhood Trauma Questionnaire (CTQ) [17, 18] . Follow-up data were collected 6 months after discharge. Table 1 summarizes the baseline demographics and characteristics of the 10 inpatients. Concerning feasibility, all patients completed the treatment. Self-rating questionnaires for evaluating the experience and acceptance of the program revealed that patients found the overall concept ‘helpful’ or ‘very helpful’. Satisfaction with the CBASP group therapy was rated as ‘high’ or ‘very high’. In addition, the acceptance of the CBASP concept by the treatment team was high. The CBASP concept proved to be feasible and there were no major difficulties integrating the concept into the daily clinical routine. The 24-item version of the Hamilton Depression Rating Scale (HAMD) [19] served as the primary outcome measure and the Beck Depression Inventory (BDI) [20] as the secondary measure. T tests for paired samples revealed significant improvements and large effect sizes in the primary outcome HAMD-24 (HAMD pre : 31.80 8 4.87; HAMD post : 14.90 8 9.40; ES pre-post : d = 2.26, T(9) = 6.33, p = 0.000) and in the BDI (BDI pre : 35.50 8 6.16; BDI post : 17.88 8 11.21; ES pre-post : d = 1.95; T(7) = 4.75, p = 0.002). Treatment response was defined a priori as a reduction in symptom severity of at least 50% on the HAMD, and remission was defined as a score of 10 or less on the HAMD scale. Figure 1 a illustrates the treatment response for each patient, demonstrating that no patient deteriorated. Six out of the 10 patients were classified as responders and 4 of these fulfilled the remission criterion. Exploratory analyses revealed that the nonresponders had a significantly higher number of personality disorders ( M = 3.25) than responders ( M = 0.66; U = 2.00; p = 0.038). In addition, the Impact Message Inventory (IMI-R) [21, 22] was used to assess the stimulus character of a patient rated by the therapist before and after treatment. The mean scores of the IMI-R are illustrated in figure 1 b and showed that the patients could change their stimulus character to be more friendly and dominant. Finally, the 6-month naturalistic follow-up assessments were completed by 9 out of the 10 patients. Outpatient psychotherapy was continued by 6 patients (CBASP: 3, cognitive-behavioral therapy: 2, schema therapy: 1), 9 patients were still on pharmacotherapy, and 6 patients regularly attended the CBASP support group. In figure 1 a, the HAMD follow-up scores for each patient in relaCognitive behavioral analysis system of psychotherapy (CBASP) was initially developed as an outpatient treatment for chronic depression [1, 2] . It integrates cognitive-emotional, behavioral, interpersonal, and psychodynamic theories and strategies by addressing directly the specific psychopathology of chronic depression. In most of the studies being conducted in outpatient settings CBASP proved to be an effective treatment [3–5] , especially in patients with early onset [5] , early trauma [4] , and in combination with medication [3] . The recently published REVAMP trial found no difference between CBASP, brief supportive therapy, or continued optimized pharmacotherapy for augmentation of antidepressant nonresponse; however, the validity of these findings is limit ed by the low number of therapy sessions used in this study [6, 7] . Given the high degree of suicidality, comorbidity, and therapy resistance in chronic depression [8–11] , however, many of these patients require inpatient treatment [12] . Here, we report on a first specialized program for chronic depression adapting CBASP to an inpatient setting. The aim of this study was to evaluate the feasibility and shortas well as long-term outcome of this program. The CBASP inpatient treatment was established at our department in 2008 and is based on the outpatient CBASP concept by McCullough [1, 2] . However, we modified his approach by implementing a multidisciplinary structured treatment program combining individual and group therapies. The manualized CBASP inpatient treatment is limited to 3 months (24 individual sessions). The new CBASP group therapy focuses on a modified approach for conducting situation analysis and on Kiesler’s circle training with the extensive use of role playing and shaping. The entire treatment team was trained in CBASP; regular workshops and weekly supervisions for both the team and the individual therapists were conducted. Specific CBASP elements were also implemented in other accompanying treatments such as nurse encounters, physiotherapy, music therapy, and occupational group therapy. A patient support group was established to avoid relapse after discharge. Received: February 3, 2010 Accepted after revision: August 26, 2010 Published online: March 10, 2011

Sensitivity to detect change and the correlation of clinical factors with the Hamilton Depression Rating Scale and the Beck Depression Inventory in depressed inpatients

Discrepancies between scores on the Hamilton Depression Rating Scale (HAMD) and the Beck Depression Inventory (BDI), as well as differences regarding their sensitivity to detect change, have been reported. This study investigates discrepancies and their potential prediction on the basis of demographic, personality, and clinical factors in depressed inpatients and analyzes the sensitivity to change. The HAMD and the BDI were administered to 105 inpatients with major depressive disorder randomized to 5 weeks of either interpersonal psychotherapy or clinical management. Personality was assessed with the NEO Five-Factor Inventory. Low extraversion and high neuroticism were associated with relatively higher endorsement of depressive symptoms on the BDI compared with the HAMD. The HAMD presented a greater reduction of symptom scores than the BDI. Patients with high BDI scores, high HAMD scores or both revealed the greatest change, possibly due to a statistical effect of regression to the mean. Restricted by sample size, analyses were not differentiated by treatment condition. Regression to the mean cannot be tested directly, but it might be considered as a possible explanation. The HAMD and the BDI should be regarded as two complementary rather than redundant or competing instruments as the discrepancy is associated with personality characteristics. Attributing large effect sizes solely to effective treatment and a sensitive measure may be misleading.

Effect of Disorder-Specific vs Nonspecific Psychotherapy for Chronic Depression: A Randomized Clinical Trial

Importance Chronic depression is a highly prevalent and disabling disorder. There is a recognized need to assess the value of long-term disorder-specific psychotherapy. Objective To evaluate the efficacy of the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) compared with that of nonspecific supportive psychotherapy (SP). Design, Setting, and Participants A prospective, multicenter, evaluator-blinded, randomized clinical trial was conducted among adult outpatients with early-onset chronic depression who were not taking antidepressant medication. Patients were recruited between March 5, 2010, and October 16, 2012; the last patient finished treatment on October 14, 2013. Data analysis was conducted from March 5, 2014, to October 27, 2016. Interventions The treatment included 24 sessions of CBASP or SP for 20 weeks in the acute phase, followed by 8 continuation sessions during the next 28 weeks. Main Outcomes and Measures The primary outcome was symptom severity after 20 weeks (blinded observer ratings) as assessed by the 24-item Hamilton Rating Scale for Depression (HRSD-24). Secondary outcomes were rates of response (reduction in HRSD-24 score of ≥50% from baseline) and remission (HRSD-24 score ⩽8), as well as self-assessed ratings of depression, global functioning, and quality of life. Results Among 622 patients assessed for eligibility, 268 were randomized: 137 to CBASP (96 women [70.1%] and 41 men [29.9%]; mean [SD] age, 44.7 [12.1] years) and 131 to SP (81 women [61.8%] and 50 men [38.2%]; mean [SD] age, 45.2 [11.6] years). The mean (SD) baseline HRSD-24 scores of 27.15 (5.49) in the CBASP group and 27.05 (5.74) in the SP group improved to 17.19 (10.01) and 20.39 (9.65), respectively, after 20 weeks, with a significant adjusted mean difference of –2.51 (95% CI, –4.16 to –0.86; P = .003) and a Cohen d of 0.31 in favor of CBASP. After 48 weeks, the HRSD-24 mean (SD) scores were 14.00 (9.72) for CBASP and 16.49 (9.96) for SP, with an adjusted difference of –3.13 (95% CI, –5.01 to –1.25; P = .001) and a Cohen d of 0.39. Patients undergoing CBASP were more likely to reach response (48 of 124 [38.7%] vs 27 of 111 [24.3%]; adjusted odds ratio, 2.02; 95% CI, 1.09 to 3.73; P = .03) or remission (27 of 124 [21.8%] vs 14 of 111 [12.6%]; adjusted odds ratio, 3.55; 95% CI, 1.61 to 7.85; P = .002) after 20 weeks. Patients undergoing CBASP showed significant advantages in most other secondary outcomes. Conclusions and Relevance Highly structured specific psychotherapy was moderately more effective than nonspecific therapy in outpatients with early-onset chronic depression who were not taking antidepressant medication. Adding an extended phase to acute psychotherapy seems promising in this population. Trial Registration clinicaltrials.gov Identifier: NCT00970437.

Behavioral Evidence for an Impairment of Affective Theory of Mind Capabilities in Chronic Depression

Background: The only treatment specifically developed for chronic depression, the Cognitive Behavioral Analysis System of Psychotherapy (CBASP), is based amongst others on the hypothesis that chronically depressed patients (CD) show considerable deficits of affective theory of mind (ToM) capabilities. Data are scarce, however, and it remains unclear if ToM deficits are specific or if they arise from global cognitive deficits associated with depression. This study investigates the specific deficits of affective ToM abilities in CD. Sampling and Methods: ToM abilities were assessed in 26 medication-free CD and 26 matched healthy controls (HC) by means of a previously established false-belief ToM cartoon task. Since the task allowed an intern control for cognitive factors - operationalized in a visuospatial ToM task - it was possible to investigate specific affective ToM deficits. Results: As hypothesized, the CD showed a significant specific slowdown of affective ToM compared to cognitive ToM (3rd person perspective) when compared to HC. Simultaneously, we observed a general deterioration of all ToM functions in CD. Conclusions: This study provides evidence that CD have a mentalization deficit, specifically for affective ToM functions. This deficit is combined with a general deterioration of ToM functions, most likely attributable to frequently described cognitive deficits in depression.

Functional Correlates of childhood maltreatment and symptom severity during affective theory of mind tasks in chronic depression

Among multiple etiological factors of depressive disorders, childhood maltreatment (CM) gains increasing attention as it confers susceptibility for depression and predisposes to chronicity. CM assumedly inhibits social-cognitive development, entailing interactional problems as observed in chronic depression (CD), especially in affective theory of mind (ToM). However, the extent of CM among CD patients varies notably as does the severity of depressive symptoms. We tested whether the extent of CM or depressive symptoms correlates with affective ToM functions in CD patients. Regional brain activation measured by functional magnetic resonance imaging during an affective ToM task was tested for correlation with CM, assessed by the Childhood Trauma Questionnaire (CTQ), and symptom severity, assessed by the Montgomery-Åsberg Depression Rating Scale (MADRS), in 25 unmedicated CD patients (mean age 41.52, SD 11.13). Amygdala activation during affective ToM correlated positively with CTQ total scores, while (para)hippocampal response correlated negatively with MADRS scores. Our findings suggest that differential amygdala activation in affective ToM in CD is substantially modulated by previous CM and not by the pathophysiological equivalents of current depressive symptoms. This illustrates the amygdalas role in the mediation of CM effects. The negative correlation of differential (para)hippocampal activation and depressive symptom severity indicates reduced integration of interactional experiences during depressive states.

Allgemeine Wirkfaktoren bei der Behandlung chronisch depressiver Patienten – Vergleich zweier Psychotherapieansätze

Hintergrund: Das Ausmaß, in dem allgemeine Wirkfaktoren die Wirksamkeit von Psychotherapie bei chronischer Depression beeinflussen, ist bisher wenig untersucht: Welche allgemeinen Wirkfaktoren unterscheiden erfolgreiche und weniger erfolgreiche Psychotherapien bei chronisch depressiven Patienten? Patienten und Methoden: Mit Hilfe des Berner Patienten- und Therapeutenstundenbogens (TSTB/PSTB) wurden bei 29 chronisch depressiven Patienten während einer 16-wöchigen Behandlung mit dem Cognitive Behavioral Analysis System of Psychotherapy (CBASP) oder der Interpersonellen Psychotherapie (IPT) wöchentlich die Wirkfaktoren erhoben und mittels Varianzanalyse verglichen. Als primäres Erfolgsmaß diente die 24-Item Hamilton Depressionsskala (HRSD-24). Ergebnisse: Aus Patientensicht zeigten sich signifikante Unterschiede zwischen erfolgreichen (Response-Kriterium definiert als mindestens 50%-Verbesserung im HRSD-24) und weniger erfolgreichen Therapien im Ausmaß «Motivationaler Klärung» (p = 0,02) und «Problembewältigung» (p = 0,01). Es konnten keine bedeutsamen Unterschiede bezüglich allgemeiner Wirkfaktoren von CBASP- versus IPT-Therapien nachgewiesen werden. Diskussion: Unabhängig von der spezifischen Therapiemethode bestätigt sich aus Patientensicht die Bedeutung intensiver Motivationaler Klärung sowie bewältigender Strategien für eine erfolgreiche Behandlung chronischer Depressionen.

Sleep quality changes in chronically depressed patients treated with Mindfulness-based Cognitive Therapy or the Cognitive Behavioral Analysis System of Psychotherapy: a pilot study

OBJECTIVE To capture any sleep quality changes associated with group psychotherapy. PATIENTS/METHODS Physician-referred, chronically depressed patients (n = 25) were randomized to either eight group sessions of Mindfulness-based Cognitive Therapy (MBCT, n = 9) plus Treatment As Usual (TAU), or the Cognitive Behavioral Analysis System of Psychotherapy (CBASP, n = 8) plus TAU, or to TAU only (control group, n = 8). Participants recorded their sleep at home. The primary outcome variables were: stable and unstable sleep, which were assessed using cardiopulmonary coupling (CPC) analysis, and estimated total sleep and wake time (minutes). Cardiopulmonary coupling measures heart rate variability and the electrocardiograms R-wave amplitude fluctuations associated with respiration. RESULTS By post-treatment night 6, the CBASP group had more stable sleep (p= 0.044) and less wake (p = 0.004) compared with TAU, and less wake vs MBCT (p = 0.039). CONCLUSION The CBASP group psychotherapy treatment improved sleep quality compared with Treatment As Usual.

Wie adhärent wird Clinical Management in randomisierten, kontrollierten Studien durchgeführt?

CM is increasingly used as a control condition in depression research. In the present study, the adherence of standardized CM sessions and their influence on outcome in depressed inpatients was investigated for the first time. In a randomized controlled trial, 43 inpatients with a diagnosis of Major Depression received medication treatment plus three-weekly CM sessions for 5 weeks. The 17-item version of the Hamilton Depression Rating Scale was the outcome measure. A total of 167 randomly selected audiotapes of CM sessions were evaluated using an adherence scale. The CM sessions delivered by psychiatric residents showed overall a high quality and included extensive support by the physician. The length of sessions was extended. The purity of sessions was associated with higher response rates. A diagnosis of Axis II-disorders or -traits and the clinical experience of the physician in years were predictors for less adherend treatments. However, both of them did not function as moderator variables.

Does Childhood Maltreatment Moderate the Effect of the Cognitive Behavioral Analysis System of Psychotherapy versus Supportive Psychotherapy in Persistent Depressive Disorder

that compared CBASP with supportive psychotherapy (SP) [5] . CBASP targets specific maladaptive interpersonal behaviors that are associated with PDD and CM [6] . We have therefore hypothesized that CBASP is more effective than SP in patients retrospectively reporting CM. For the full description of the study, refer to the published protocol [7] and the main results [5] . Hereafter, only the aspects pertaining to the subgroup analysis will be reiterated. The acute treatment phase consisted of 24 sessions of CBASP or SP over 20 weeks. The primary outcome was depression severity as assessed by the 24-item version of the clinician-rated Hamilton Rating Scale for Depression (HRSD-24) at the end of the acute treatment phase. CM was assessed using the short form of the Childhood Trauma Questionnaire (CTQ-SF). The CTQ-SF consists of 28 self-report items that assess CM before the age of 18. It consists of 5 subscales: emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect. For this analysis, the presence of CM was defined as at least moderate to severe self-reported CM in at least one of these subscales. References for the outcome measures can be found at http://bit.ly/PPS484412. The statistical analysis was prespecified in the study protocol. It was performed on the modified intention-to-treat population that included all randomized patients for whom CTQ-SF data were available (256 out of 268, 95.5%). Missing outcome data at week 20 were imputed using the last observation carried forward method. The primary analysis was an analysis of covariance including fixed effects of group allocation, baseline HRSD-24 score, trial site, and presence of CM as main effects and the “treatment × presence of CM” interaction. The hypothesis that CM has a moderating influence on the efficacy of treatment was tested with the interaction term. We also conducted secondary exploratory analyses to discover which subtypes of CM have a moderating effect. Three quarters of the patients ( n = 190, 74.2%) reported at least moderate to severe CM. The most common forms of CM were emotional neglect ( n = 167, 65.5%) and emotional abuse ( n = 151, 59.0%) (see supplemental Table 1 at http://bit.ly/PPS484412). As reported previously [5] , CBASP was superior to SP in the reduction of depressive symptoms with a between-group effect of d = 0.31 at 20 weeks. Our main analysis revealed that the presence of CM had a moderating influence on the efficacy of treatment ( F 1, 244 = 4.253, p = 0.040; Fig. 1 ). The between-group effect was d = 0.49 in favor of CBASP in the subgroup of patients who reported CM ( d = –0.10 with no CM). The main effect of CM was not statistically significant ( F 1, 244 = 1.888, p = 0.171) indicating that CM did not predict outcome independent of treatment allocation. With regard to subtypes of CM, secondary analyses found that only emotional abuse had a significant moderating effect on the efficacy of treatment ( F 1, 244 = 6.866, p = 0.009). Here, the betweengroup effect was d = 0.60 in favor of CBASP in the subgroup of patients who reported CM ( d = –0.06 with no CM). This result can also be considered statistically significant if the threshold for sigIn the treatment of major depression, childhood maltreatment (CM) has been associated with an unfavorable outcome [1] . One possible exception might be psychotherapy with the cognitive behavioral analysis system of psychotherapy (CBASP). One study in patients with persistent depressive disorder (PDD) demonstrated that CBASP was more effective in those reporting CM than those not reporting CM [2] . CBASP is a treatment model that has been developed specifically for patients with PDD. In 2 trials comparing CBASP to other forms of psychotherapy, CBASP appeared to be superior to interpersonal psychotherapy (IPT) [3] and to other evidence-based psychotherapies including IPT and cognitive behavioral therapy (CBT) [4] . It is unclear however, whether the superiority of CBASP compared to other methods of psychotherapy is influenced by CM. The goal of the present study was to examine the impact of CM on the efficacy of CBASP in a prospective, multicenter, evaluator-blinded randomized clinical trial of unmedicated adult outpatients (18–65 years old) with early-onset PDD Received: June 28, 2017 Accepted after revision: October 19, 2017 Published online: January 6, 2018