The Place of CT as an Empirically Supported Therapy for Depression

CT for depression has been subjected to a large number of investigations, some of which have examined CT in its own right, whereas others have compared CT to alternative treatments. The earliest comparative trial contrasted the efficacy of CT and that of tricyclic medication, and found that the two treatments had roughly equivalent outcomes (Rush et al., 1977, 1978). This early success lead to a number of trials, the most notable of which was the Treatments of Depression Comparative Research Program (TDCRP; Elkin et al., 1989) sponsored by the National Institute of Mental Health (NIMH). This large, multisite study compared CT to another short-term psychotherapy, interpersonal therapy (IPT; Klerman, Weissman, Rounsaville, & Chevron, 1984), and to tricyclic medications. Whereas the overall treatment outcomes were roughly equivalent, patients with higher initial depression severity who were assigned to CT did relatively less well than patients assigned to either IPT or medication. This "treatment X severity interaction" has led to the popular idea that CT is mostly effective for mild-to-moderate levels of depression, and to treatment guidelines that also reify this idea, such as those by the American Psychiatric Association (www.psych.org/psych_pract/treatg/pg/mdd2E_05-15-06.pdf ).

The conclusion regarding the treatment equivalency of CT and other treatments, and the recommendation that CT be used only for mild-to-moderate depression are both called into question by other, more recent data. Two meta-analyses of CT for depression have now been completed (Dobson, 1989; Gloaguen, Cottraux, Cucherat, & Blackburn, 1998). Both analyses used the BDI as an outcome measure and compared CT to four other types of treatments: waiting list/no treatment; behavior therapy, pharmacotherapy, and other psychotherapies. The absolute effect size for CT compared to no treatment was 1.86 in the Dobson (1989) study, and the approximate average effect size for the other comparisons was 0.50, indicating that patients treated with CT were half a standard deviation lower on the BDI at posttest compared to other treatments. Gloaguen et al. (1998) reported that the comparison between CT and no treatment remained large, and that whereas CT still demonstrated a statistically significant advantage over both pharmacotherapy and other psychotherapies, the effect size was smaller than earlier reported. Notably, the comparison between CT and behavior therapy failed to show an advantage for either treatment. Finally, Gloaguen et al. presented the follow-up data for the comparisons between CT and pharmacotherapy, and concluded that naturalistic follow-up relapse rates over approximately a 1- to 2-year follow-up period were about half the rates reported for medication conditions.

The treatment X severity interaction effect discussed earlier was subjected to a further "mega-analysis" (DeRubeis, Gelfand, Tang, & Simons, 1999). This study combined the raw data from four independent comparative trials of CT and pharmacotherapy (including the NIMH TDCRP data), and despite several ways of examining the data, failed to find the interaction effect. DeRubeis et al.'s argument, based on their analyses with more statistical power and more sophisticated data methods, was that the treatment X severity interaction did not in fact exist, and that these treatments were equally efficacious in both less and more severely depressed patients. These predictions have subsequently been borne out in two recent studies. One of these studies was completed at two sites and only employed more severely depressed patients (DeRubeis et al., 2005; Hollon et al., 2005). Results indicated roughly equivalent outcomes between CT and selective serotonin reuptake inhibitor (SSRI) medications in the short term, but significantly better survival (i.e., less depression relapse/recurrence) in the group previously treated with CT as opposed to that treated with antide-pressant medication. These results have been replicated in a more recent trial (Dimidjian et al., 2006; Dobson et al., 2007).

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