Therapy Effective and Efficient Long-Term For Depression

Justin Karter
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There is robust evidence for the long-term effectiveness of psychotherapy, and it also provides good value-for-money, according to a large randomized control trial published open-access this month in The Lancet. The researchers recommend that clinicians refer all patients with treatment-resistant depression to therapy.

CoBalT aims to find out whether giving CBT in addition to antidepressants can improve outcomes for people with treatment resistant depression, compared to antidepressant treatment alone.
CoBalT aims to find out whether giving CBT in addition to antidepressants can improve outcomes for people with treatment-resistant depression, compared to antidepressant treatment alone.

The researchers examined a particular style of therapy, Cognitive Behavioral Therapy (CBT), which past research has shown to be a particularly effective treatment for depression. They explain that CBT “teaches patients skills to help them better manage their mood, and so has the potential to result in a benefit that is sustained beyond the end of therapy.” While CBT has been tested and found effective for depression, including treatment-resistant depression, few studies have tracked the long-term results of this approach.

Treatment-resistant depression (TRD), which is also referred to as “refractory depression,” “chronic depression,” and “difficult-to-treat depression,”  is commonly defined by the failure to respond to two different antidepressants. However, the past research indicates that approximately 60% of patients do not respond to antidepressants and that, therefore, “treatment-resistance” might be better characterized as a diagnostic “paradigm failure.”

Current treatment guidelines suggest that antidepressants be used over psychotherapy for major depressive disorder. An analysis published in JAMA in September, however, found that “patients with more severe depression were no more likely to require medications to improve than patients with less severe depression.” The same study also suggested that CBT may be used an effective first-line treatment for severely depressed patients.

The current study is based on the long-term follow-up data from the CoBalT trial, a pragmatic, multicentre randomized control trial across seventy-three treatment centers in the UK that investigated cognitive-behavioral therapy as an adjunct therapy to antidepressants for treatment-resistant depression. The CoBalT trial study authors estimate that “two-thirds of people with depression don’t respond fully to antidepressants, even after an adequate dose and duration of treatment.”

The study aimed “to examine whether CBT (in addition to usual care that included pharmacotherapy) was effective and cost efficient in reducing depressive symptoms and improving quality of life over the long-term (3–5 years) compared with usual care alone in primary care patients.”

After receiving 12-18 sessions of CBT the patients were asked to respond to a questionnaire by mail, assessing their depressive symptoms over the next three to five years. After controlling for demographic differences and other potential confounders, the researchers found that participants who received therapy had significantly less depressive symptoms at follow-up.

“Individuals in the intervention group had nearly a three-fold increased odds of response over the 46 months compared with those in the usual care group,” the researchers write.

Those who received CBT were also more likely to experience remission, report reduced anxiety, and show greater improvement in overall mental health. Also, those who received therapy were less likely to be taking antidepressants at 46 weeks.

To evaluate the cost-effectiveness of CBT, the researchers obtained health care resource records and estimated participants use of health care services over the follow-up period. It was estimated that the averages cost per patient for the CBT intervention was £343, but that health and social services costs were higher in the usual care group over the long-term.

“CBT as an adjunct to usual care was an effective treatment for primary care patients with treatment-resistant depression over the long-term, and represented good value for money,” the researchers concluded. “Clinicians need to discuss referral for CBT with all those for whom antidepressants are not effective.”

 

 

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Wiles, N. J., Thomas, L., Turner, N., Garfield, K., Kounali, D., Campbell, J., … & Williams, C. (2016). Long-term effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: follow-up of the CoBalT randomised controlled trial. The Lancet Psychiatry. (Full text)

7 COMMENTS

      • It probably also means they had a hard time finding anyone with this diagnosis who wasn’t already being “treated” chemically. Don’t know how it could be “unethical” not to “treat” with antidepressants after Kirsch’s work showing that they are barely better than placebo for most cases.

        I find it odd that they recommend CBT for “treatment resistant depression” when it’s clear that it should be the first line treatment, and drugs only used when therapy of some sort fails. Of course, there are tons of other options outside the paradigm that says depressed people need “treatment” for a “disorder,” but operating within their own paradigm, this suggests that drug treatment should be ancillary and therapy primary in all cases, which is the opposite of what we see today.

        — Steve

  1. Meanwhile, as this is the only “depression” conversation going on right now, check this out:

    The current issue of Psychiatric Times features a questionnaire to its (professional) readers asking what treatment choices they would like to see explored in a randomized study of “treatment resistant depression” (TRD) in people 60 years old and over. The choices, in their entirety, are:

    Augmentation with aripiprazole
    Augmentation with bupropion
    Augmentation with lithium
    Switching to bupropion
    Switching to nortriptyline
    Other (please specify)

    Psychotherapy is not even considered, of course.

    (https://www.research.net/r/GDRLPSX)

  2. CBT is a bandaid. It doesn’t address the long term ACEs responsible for treatment resistant depression in the first place. I’m speaking as somebody who’s been there/done that with CBT. It never ever ever addressed the ACEs. In fact, even the ACEs themselves don’t address ALL of them (for me- stuff from growing up with a disability). It’s a vanilla pudding one-size-better-fit-all approach. And the assumption that Things go Better with Pills is wrong, too. …. Somewhere I read an article about some Scandinavian country that went Whole Hog on CBT and EVERYONE used it (since it was so good!)… And their post test (after EVERYBODY used it) was absolutely unremarkable.

  3. I believe psychological talk therapy theories, like CBT, if not augmented with psychological belief in the DSM disorders, like depression, could possibly be a valid alternative to real life problems in life. Although, my psychologist was a believer in the DSM, not CBT, so my experience of CBT is limited.

    In other words, I personally found my psychologist, who claimed to be a “holistic, Christian talk therapist,” whose actual goal I learned from reading her medical records, was to cover up my child abuse concerns, for her pastor. Resulting in her staunch belief in the psychiatric DSM drugging system only, rather than any actual psychotherapy, and was thus extremely harmful to me, rather than helpful.

    And the medical evidence does now prove drugging up child abuse victims with the antipsychotics, does indeed, create a lot of “incurable” “schizophrenics,” since 2/3s of today’s so called “schizophrenics” are, indeed, child abuse victims.

    Especially since it is already medically known the antipsychotics do cause both the negative symptoms of “schizophrenia,” via neuroleptic induced deficit syndrome” and the positive symptoms of ‘schizophrenia,” via anticholinergic toxidrome.

    I do so hope the psychiatric and psychological industries will some day get out of the business of profiting off to covering up child abuse for the religions, by defaming, drugging, torturing, and trying to murder those who are dealing with religious cover ups of the abuse of children.