Steven D. Hollon

Defining Empirically Supported Therapies

A scheme is proposed for determining when a psychological treatment for a specific problem or disorder may be considered to be established in efficacy or to be possibly efficacious. The importance of independent replication before a treatment is established in efficacy is emphasized, and a number of factors are elaborated that should be weighed in evaluating whether studies supporting a treatments efficacy are sound. It is suggested that, in evaluating the benefits of a given treatment, the greatest weight should be given to efficacy trials but that these trials should be followed by research on effectiveness in clinical settings and with various populations and by cost-effectiveness research.

Antidepressant Drug effects and Depression Severity: A Patient-Level Meta-Analysis

CONTEXT Antidepressant medications represent the best established treatment for major depressive disorder, but there is little evidence that they have a specific pharmacological effect relative to pill placebo for patients with less severe depression. OBJECTIVE To estimate the relative benefit of medication vs placebo across a wide range of initial symptom severity in patients diagnosed with depression. DATA SOURCES PubMed, PsycINFO, and the Cochrane Library databases were searched from January 1980 through March 2009, along with references from meta-analyses and reviews. STUDY SELECTION Randomized placebo-controlled trials of antidepressants approved by the Food and Drug Administration in the treatment of major or minor depressive disorder were selected. Studies were included if their authors provided the requisite original data, they comprised adult outpatients, they included a medication vs placebo comparison for at least 6 weeks, they did not exclude patients on the basis of a placebo washout period, and they used the Hamilton Depression Rating Scale (HDRS). Data from 6 studies (718 patients) were included. DATA EXTRACTION Individual patient-level data were obtained from study authors. RESULTS Medication vs placebo differences varied substantially as a function of baseline severity. Among patients with HDRS scores below 23, Cohen d effect sizes for the difference between medication and placebo were estimated to be less than 0.20 (a standard definition of a small effect). Estimates of the magnitude of the superiority of medication over placebo increased with increases in baseline depression severity and crossed the threshold defined by the National Institute for Clinical Excellence for a clinically significant difference at a baseline HDRS score of 25. CONCLUSIONS The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial.

Cognitive self-statements in depression: Development of an automatic thoughts questionnaire

A 30-item questionnaire was devised to measure the frequency of occurrence of automatic negative thoughts (negative self-statements)associated with depression. Male and female undergraduates were asked to recall dysphoric experiences and to report associated cognitions. One hundred representative cognitions were selected and administered to a second sample, along with the MMPI D scale and the Beck Depression Inventory. Thirty items discriminating between criterion groups of psychometrically depressed and nondepressed subjects were identified. The resultant 30-item automatic thoughts questionnaire (ATQ-30)was cross-validated and found to significantly discriminate psychometrically depressed from nondepressed criterion groups. No differences were found between males and females on the measure. Factor analysis indicated a four-factor solution, with a large first factor reflecting Personal Maladjustment, a second factor indicative of Negative Self-Concept and Negative Expectations, and two lesser factors. The ATQ-30 may provide a means of testing basic theory relating cognitive content to behavioral and affective processes and assessing change in cognitions associated with experimental manipulation or psychotherapeutic intervention.

Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression

Antidepressant medication is considered the current standard for severe depression, and cognitive therapy is the most widely investigated psychosocial treatment for depression. However, not all patients want to take medication, and cognitive therapy has not demonstrated consistent efficacy across trials. Moreover, dismantling designs have suggested that behavioral components may account for the efficacy of cognitive therapy. The present study tested the efficacy of behavioral activation by comparing it with cognitive therapy and antidepressant medication in a randomized placebo-controlled design in adults with major depressive disorder (N = 241). In addition, it examined the importance of initial severity as a moderator of treatment outcome. Among more severely depressed patients, behavioral activation was comparable to antidepressant medication, and both significantly outperformed cognitive therapy. The implications of these findings for the evaluation of current treatment guidelines and dissemination are discussed.

Issues and recommendations regarding use of the Beck Depression Inventory

Issues concerning use of the Beck Depression Inventory (BDI) for the self-report of depressive symptomatology are raised and considered. Discussion includes the stability of depression and the need for multiple assessment periods, specificity and the need for multiple assessment measures, and selection cut scores and the need for terminological accuracy. Recommendations for the continued use of the BDI, designed to facilitate the integration of diverse studies and improve research on self-reported depression, are provided.

The investigation of schematic content and processing in eating disorders

The core psychopathology of anorexia nervosa and bulimia nervosa is hypothesized to be represented in organized cognitive structures that unite views of the self with beliefs about weight. These weight-related self-schemata may exert automatic effects on the processing of information, and may also help to account for the clinical observation that patients frequently regard their symptoms as serving a valued function. Strategies for assessing the presence and operation of self-schemata in the eating disorders are outlined, and the limitations of inventories designed to measure self-statements about food and weight are emphasized. It is suggested that the “cognitive essence” of these disorders may be found in potent and inclusive schemata that reduce ambiguity, facilitate judgments and predictions, and provide a simple set of premises from which specific rules can be deduced. Several constructs are recommended for further study, including a preference for simplicity, a preference for certainty, and a distinctive “New Years resolution” cognitive style.

Cognitive therapy versus medication for depression: treatment outcomes and neural mechanisms

Depression is one of the most prevalent and debilitating of the psychiatric disorders. Studies have shown that cognitive therapy is as efficacious as antidepressant medication at treating depression, and it seems to reduce the risk of relapse even after its discontinuation. Cognitive therapy and antidepressant medication probably engage some similar neural mechanisms, as well as mechanisms that are distinctive to each. A precise specification of these mechanisms might one day be used to guide treatment selection and improve outcomes.

Treatment and Prevention of Depression

Depression is one of the most common and debilitating psychiatric disorders and is a leading cause of suicide. Most people who become depressed will have multiple episodes, and some depressions are chronic. Persons with bipolar disorder will also have manic or hypomanic episodes. Given the recurrent nature of the disorder, it is important not just to treat the acute episode, but also to protect against its return and the onset of subsequent episodes. Several types of interventions have been shown to be efficacious in treating depression. The antidepressant medications are relatively safe and work for many patients, but there is no evidence that they reduce risk of recurrence once their use is terminated. The different medication classes are roughly comparable in efficacy, although some are easier to tolerate than are others. About half of all patients will respond to a given medication, and many of those who do not will respond to some other agent or to a combination of medications. Electro-convulsive therapy is particularly effective for the most severe and resistant depressions, but raises concerns about possible deleterious effects on memory and cognition. It is rarely used until a number of different medications have been tried. Although it is still unclear whether traditional psychodynamic approaches are effective in treating depression, interpersonal psychotherapy (IPT) has fared well in controlled comparisons with medications and other types of psychotherapies. It also appears to have a delayed effect that improves the quality of social relationships and interpersonal skills. It has been shown to reduce acute distress and to prevent relapse and recurrence so long as it is continued or maintained. Treatment combining IPT with medication retains the quick results of pharmacotherapy and the greater interpersonal breadth of IPT, as well as boosting response in patients who are otherwise more difficult to treat. The main problem is that IPT has only recently entered clinical practice and is not widely available to those in need. Cognitive behavior therapy (CBT) also appears to be efficacious in treating depression, and recent studies suggest that it can work for even severe depressions in the hands of experienced therapists. Not only can CBT relieve acute distress, but it also appears to reduce risk for the return of symptoms as long as it is continued or maintained. Moreover, it appears to have an enduring effect that reduces risk for relapse or recurrence long after treatment is over. Combined treatment with medication and CBT appears to be as efficacious as treatment with medication alone and to retain the enduring effects of CBT. There also are indications that the same strategies used to reduce risk in psychiatric patients following successful treatment can be used to prevent the initial onset of depression in persons at risk. More purely behavioral interventions have been studied less than the cognitive therapies, but have performed well in recent trials and exhibit many of the benefits of cognitive therapy. Mood stabilizers like lithium or the anticonvulsants form the core treatment for bipolar disorder, but there is a growing recognition that the outcomes produced by modern pharmacology are not sufficient. Both IPT and CBT show promise as adjuncts to medication with such patients. The same is true for family-focused therapy, which is designed to reduce interpersonal conflict in the family. Clearly, more needs to be done with respect to treatment of the bipolar disorders. Good medical management of depression can be hard to find, and the empirically supported psychotherapies are still not widely practiced. As a consequence, many patients do not have access to adequate treatment. Moreover, not everyone responds to the existing interventions, and not enough is known about what to do for people who are not helped by treatment. Although great strides have been made over the past few decades, much remains to be done with respect to the treatment of depression and the bipolar disorders.

Prevention of depression in at-risk adolescents: a randomized controlled trial.

CONTEXT Adolescent offspring of depressed parents are at markedly increased risk of developing depressive disorders. Although some smaller targeted prevention trials have found that depression risk can be reduced, these results have yet to be replicated and extended to large-scale, at-risk populations in different settings. OBJECTIVE To determine the effects of a group cognitive behavioral (CB) prevention program compared with usual care in preventing the onset of depression. DESIGN, SETTING, AND PARTICIPANTS A multicenter randomized controlled trial conducted in 4 US cities in which 316 adolescent (aged 13-17 years) offspring of parents with current or prior depressive disorders were recruited from August 2003 through February 2006. Adolescents had a past history of depression, current elevated but subdiagnostic depressive symptoms, or both. Assessments were conducted at baseline, after the 8-week intervention, and after the 6-month continuation phase. INTERVENTION Adolescents were randomly assigned to the CB prevention program consisting of 8 weekly, 90-minute group sessions followed by 6 monthly continuation sessions or assigned to receive usual care alone. MAIN OUTCOME MEASURE Rate and hazard ratio (HR) of a probable or definite depressive episode (ie, depressive symptom rating score of > or = 4) for at least 2 weeks as diagnosed by clinical interviewers. RESULTS Through the postcontinuation session follow-up, the rate and HR of incident depressive episodes were lower for those in the CB prevention program than for those in usual care (21.4% vs 32.7%; HR, 0.63; 95% confidence interval [CI], 0.40-0.98). Adolescents in the CB prevention program also showed significantly greater improvement in self-reported depressive symptoms than those in usual care (coefficient, -1.1; z = -2.2; P = .03). Current parental depression at baseline moderated intervention effects (HR, 5.98; 95% CI, 2.29-15.58; P = .001). Among adolescents whose parents were not depressed at baseline, the CB prevention program was more effective in preventing onset of depression than usual care (11.7% vs 40.5%; HR, 0.24; 95% CI, 0.11-0.50), whereas for adolescents with a currently depressed parent, the CB prevention program was not more effective than usual care in preventing incident depression (31.2% vs 24.3%; HR, 1.43; 95% CI, 0.76-2.67). CONCLUSION The CB prevention program had a significant prevention effect through the 9-month follow-up period based on both clinical diagnoses and self-reported depressive symptoms, but this effect was not evident for adolescents with a currently depressed parent. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00073671.

Randomized Trial of Behavioral Activation, Cognitive Therapy, and Antidepressant Medication in the Prevention of Relapse and Recurrence in Major Depression

This study followed treatment responders from a randomized controlled trial of adults with major depression. Patients treated with medication but withdrawn onto pill-placebo had more relapse through 1 year of follow-up compared to patients who received prior behavioral activation, prior cognitive therapy, or continued medication. Prior psychotherapy was also superior to medication withdrawal in the prevention of recurrence across the 2nd year of follow-up. Specific comparisons indicated that patients previously exposed to cognitive therapy were significantly less likely to relapse following treatment termination than patients withdrawn from medication, and patients previously exposed to behavioral activation did almost as well relative to patients withdrawn from medication, although the difference was not significantly different. Differences between behavioral activation and cognitive therapy were small in magnitude and not significantly different across the full 2-year follow-up, and each therapy was at least as efficacious as the continuation of medication. These findings suggest that behavioral activation may be nearly as enduring as cognitive therapy and that both psychotherapies are less expensive and longer lasting alternatives to medication in the treatment of depression.