Effectiveness of Cognitive Behavioral Therapy in Public Mental Health: Comparison to Treatment as Usual for Treatment-Resistant Depression

Original Article

Abstract

State mental health systems have been leaders in the implementation of evidence-based approaches to care for individuals with severe mental illness. Numerous case studies of the wide-scale implementation of research-supported models such as integrated dual diagnosis treatment and assertive community treatment are documented. However, relatively few dissemination efforts have focused on cognitive behavioral therapy (CBT) for individuals with major depression despite evidence indicating its efficacy with this population. A multi-site effectiveness trial of CBT was conducted within the Texas public mental health system. Eighty-three adults with major depression received CBT from community clinicians trained through a workshop and regular consultation with a master clinician. Outcomes were compared to a matched sample of individuals receiving pharmacotherapy. Outcome measures used included the quick inventory of depressive symptomatology and beck depression inventory. Individuals receiving CBT showed greater improvements in depression symptoms than those in the comparison group. Greater pre-treatment symptom severity predicted better treatment response, while the presence of comorbid personality disorders was associated with poorer outcomes.

Keywords

Cognitive behavioral therapy Depression Evidence-based practices Effectiveness 

References

  1. Addis, M. E. (2002). Methods for disseminating research products and increasing evidence-based practice: Promises, obstacles, and future directions. Clinical Psychology: Science and Practice, 9(4), 367–378.Google Scholar
  2. Addis, M. E., & Krasnow, A. D. (2000). A national survey of practicing psychologists’ attitudes toward psychotherapy treatment manuals. Journal of Consulting and Clinical Psychology, 68(2), 331.PubMedCrossRefGoogle Scholar
  3. American Psychiatric Association (2010). Practice guideline for the treatment of patients with major depressive disorder, (3rd ed.). Available from http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1667485.
  4. American Psychiatric Association, & American Psychiatric Association Task Force on DSM-IV. (1994). Diagnostic and statistical manual of mental disorders: DSM-IV. American Psychiatric Pub Inc.Google Scholar
  5. Anderberg, M. R. (1973). Cluster analysis for applications. New York: Academic Press.Google Scholar
  6. Antonuccio, D. O., Thomas, M., & Danton, W. G. (1997). A cost-effectiveness analysis of cognitive behavior therapy and fluoxetine (Prozac) in the treatment of depression. Behavior Therapy, 28(2), 187–210.CrossRefGoogle Scholar
  7. Baldwin, S. A., Bauer, D. J., Stice, E., & Rohde, P. (2011). Evaluating models for partially clustered designs. Psychological Methods, 16, 149.PubMedCentralPubMedCrossRefGoogle Scholar
  8. Barber, J. P., Sharpless, B. A., Klostermann, S., & McCarthy, K. S. (2007). Assessing intervention competence and its relation to therapy outcome: A selected review derived from the outcome literature. Professional Psychology: Research and Practice, 38, 493–500.CrossRefGoogle Scholar
  9. Bauer, D. J., Sterba, S. K., & Hallfors, D. D. (2008). Evaluating group-based interventions when control participants are ungrouped. Multivariate Behavioral Research, 43, 210–236.PubMedCentralPubMedCrossRefGoogle Scholar
  10. Beck, A. T., Epstein, N., Brown, G., & Steer, R. (1988). An inventory for measuring clinical anxiety. Journal of Consulting and Clinical Psychology, 56, 893–897.PubMedCrossRefGoogle Scholar
  11. Beck, A. T., Rush, A. J., Shaw, B., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press.Google Scholar
  12. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck depression inventory manual. Google Scholar
  13. Beck, A. T., Ward, C. H., Mendelsohn, M., Mock, J., & Erlbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561–571.PubMedCrossRefGoogle Scholar
  14. Becker, C. B., Zayfert, C., & Anderson, E. (2004). A survey of psychologists’ attitudes towards and utilization of exposure therapy for PTSD. Behavior Research and Therapy, 42(3), 277–292.CrossRefGoogle Scholar
  15. Burnham, K. P., & Anderson, D. (2002). Model selection and multi-model inference: A practical information-theoretic approach. New York, NY: Springer.Google Scholar
  16. Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26, 17–31.PubMedCrossRefGoogle Scholar
  17. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Earlbaum Associates.Google Scholar
  18. Cook, J. A., Toprac, M., & Shore, S. E. (2004). Combining evidence-based practice with stakeholder consensus to enhance psychosocial rehabilitation services in the Texas benefit design initiative. Psychiatric Rehabilitation Journal, 27, 307–318.PubMedCrossRefGoogle Scholar
  19. Cuijpers, P., Dekker, J., Hollon, D. S., & Andersson, G. (2009). Adding psychotherapy to pharmacotherapy in the treatment of depressive disorders in adults: A meta-analysis. Journal of Clinical Psychiatry, 70(9), 1219–1229.PubMedCrossRefGoogle Scholar
  20. Cuijpers, P., Huibers, M., Ebert, D. D., Koole, S. L., & Andersson, G. (2013a). How much psychotherapy is needed to treat depression? Journal of Affective Disorders, 149(1–3), 1–13.PubMedCrossRefGoogle Scholar
  21. Cuijpers, P., Sijbrandij, M., Koole, S. L., Andersson, G., Beekman, A. T., & Reynolds, C. F. (2013b). The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: A meta-analysis of direct comparisons. World Psychiatry, 12(2), 137–148.PubMedCentralPubMedCrossRefGoogle Scholar
  22. Cuijpers, P., van Straten, A., Schuurmans, J., van Oppen, P., Hollon, S. D., & Andersson, G. (2010). Psychotherapy for chronic major depression and dysthymia: A meta-analysis. Clinical Psychology Review, 30, 51–62.PubMedCrossRefGoogle Scholar
  23. David, D., Szentagotai, A., Lupu, V., & Cosman, D. (2008). Rational emotive behavior therapy, cognitive therapy, and medication in the treatment of major depressive disorder: A randomized clinical trial, posttreatment outcomes, and six-month follow-up. Journal of Clinical Psychology, 64(6), 728–746.PubMedCrossRefGoogle Scholar
  24. DeRubeis, R. J., Hollon, S. D., Amsterdam, J. D., Shelton, R. C., Young, P. R., Salomon, R. M., et al. (2005). Cognitive therapy vs. medications in the treatment of moderate to severe depression. Archives of General Psychiatry, 62, 409–416.PubMedCrossRefGoogle Scholar
  25. Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis, M. E., et al. (2006). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of Consulting and Clinical Psychology, 74, 658–670.PubMedCrossRefGoogle Scholar
  26. Driessen, E., Cuijpers, P., Hollon, S. D., & Dekker, J. J. (2010). Does pretreatment severity moderate the efficacy of psychological treatment of adult outpatient depression? A meta-analysis. Journal of Consulting and Clinical Psychology, 78(5), 668.PubMedCrossRefGoogle Scholar
  27. Feldman, G. (2007). Cognitive and behavioral therapies for depression: Overview, new directions, and practical recommendations for dissemination. Psychiatric Clinics of North America, 30(1), 39–50.PubMedCrossRefGoogle Scholar
  28. Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Publication #231).Google Scholar
  29. Foa, E. B., Gillihan, S. J., & Bryant, R. A. (2013). Challenges and successes in dissemination of evidence-based treatments for posttraumatic stress: Lessons learned from prolonged exposure therapy for PTSD. Psychological Science in the Public Interest, 14(2), 65–111.CrossRefGoogle Scholar
  30. Fournier, J. C., DeRubeis, R. J., Shelton, R. C., Gallop, R., Amsterdam, J. D., & Hollon, S. D. (2008). Antidepressant medications v. cognitive therapy in people with depression with or without personality disorder. The British Journal of Psychiatry, 192(2), 124–129.PubMedCentralPubMedCrossRefGoogle Scholar
  31. Fournier, J. C., DeRubeis, R. J., Shelton, R. C., Hollon, S. D., Amsterdam, J. D., & Gallop, R. (2009). Prediction of response to medication and cognitive therapy in the treatment of moderate to severe depression. Journal of Consulting and Clinical Psychology, 77(4), 775.PubMedCentralPubMedCrossRefGoogle Scholar
  32. Hamilton, K. E., & Dobson, K. S. (2002). Cognitive therapy of depression: Pretreatment patient predictors of outcome. Clinical Psychology Review, 22(6), 875–893.PubMedCrossRefGoogle Scholar
  33. Horrell, S. C. V. (2008). Effectiveness of cognitive-behavioral therapy with adult ethnic minority clients: A review. Professional Psychology: Research and Practice, 39, 160–168.CrossRefGoogle Scholar
  34. Kazantzis, N., Deane, F. P., & Ronan, K. R. (2000). Homework assignments in cognitive and behavioral therapy: A meta-analysis. Clinical Psychology: Science and Practice, 7(2), 189–202 (Kazantzis, Deane, & Ronan).Google Scholar
  35. Lopez, M. A., & Basco, M. R. (2011). Feasibility of dissemination of cognitive behavioral therapy to Texas community mental health centers. The Journal of Behavioral Health Services & Research, 38, 91–104.CrossRefGoogle Scholar
  36. Malhi, G. S., Adams, D., Porter, R., Wignall, A., Lampe, L. O., Connor, N., et al. (2009). Clinical practice recommendations for depression. Acta Psychiatrica Scandinavica, 119(Suppl. 439), 8–26.CrossRefGoogle Scholar
  37. Manber, R., Kraemer, H. C., Arnow, B. A., Trivedi, M. H., Rush, A. J., Thase, M. E., et al. (2008). Faster remission of chronic depression with combined psychotherapy and medication than with each therapy alone. Journal of Consulting and Clinical Psychology, 76, 459–467.PubMedCentralPubMedCrossRefGoogle Scholar
  38. Merrill, K. A., Tolbert, V. E., & Wade, W. A. (2003). Effectiveness of cognitive therapy for depression in a community mental health center: A benchmarking study. Journal of Consulting and Clinical Psychology, 71(2), 404.PubMedCrossRefGoogle Scholar
  39. Meyers, D. C., Durlak, J. A., & Wandersman, A. (2012). The quality implementation framework: A synthesis of critical steps in the implementation process. American Journal of Community Psychology, 50, 462–480.PubMedCrossRefGoogle Scholar
  40. Miranda, J., Chung, J. Y., Green, B. L., Krupnick, J., Siddique, J., Revicki, D. A., et al. (2003). Treating depression in predominately low-income young minority women: A randomized controlled trial. Journal of the American Medical Association, 290, 57–65.PubMedCrossRefGoogle Scholar
  41. Mussell, M. P., Crosby, R. D., Crow, S. J., Knopke, A. J., Peterson, C. B., Wonderlich, S. A., et al. (2000). Utilization of empirically supported psychotherapy treatments for individuals with eating disorders: A survey of psychologists. International Journal of Eating Disorders, 27(2), 230–237.PubMedCrossRefGoogle Scholar
  42. Pampallona, S., Bollini, P., Tibaldi, G., Kupelnick, B., & Munizza, C. (2004). Combined pharmacotherapy and psychological treatment for depression: A systematic review. Archives of General Psychiatry, 61(7), 714.PubMedCrossRefGoogle Scholar
  43. Raudenbush, S. W., & Bryk, A. S. (2002). Hierarchical linear models: Applications and data analysis methods (Advanced Quantitative Techniques in the Social Sciences).Google Scholar
  44. Rogers, E. M. (2003). Diffusion of innovations. New York: Free Press.Google Scholar
  45. Rush, A. J., Trivedi, M. H., Ibrahim, H. M., Carmody, T. J., Arnow, B., Klein, D. N., et al. (2003). The 16-item quick inventory of depressive symptomatology (QIDS), clinician rating (QIDS–C), and self-report (QIDS–SR): A psychometric evaluation in patients with chronic major depression. Biological Psychiatry, 54(5), 573–583.PubMedCrossRefGoogle Scholar
  46. Sava, F. A., Yates, B. T., Lupu, V., Szentagotai, A., & David, D. (2009). Cost-effectiveness and cost-utility of cognitive therapy, rational emotive behavioral therapy, and fluoxetine (Prozac) in treating depression: A randomized clinical trial. Journal of Clinical Psychology, 65, 36–52.PubMedCrossRefGoogle Scholar
  47. Simons, A. D., Padesky, C. A., Montemarano, J., Lewis, C. C., Murakami, J., Lamb, K., et al. (2010). Training and dissemination of cognitive behavior therapy for depression in adults: A preliminary examination of therapist competence and client outcomes. Journal of Consulting and Clinical Psychology, 78(5), 751–756.PubMedCrossRefGoogle Scholar
  48. Sinyor, M., Schaffer, A., & Levitt, A. (2010). The sequenced treatment alternatives to relieve depression (STAR* D) trial: A review. Canadian Journal of Psychiatry, 55(3), 126–135.Google Scholar
  49. Stirman, S. W., Crits-Christoph, P. C., & DeRubeis, R. J. (2004). Achieving successful dissemination of empirically supported psychotherapies: A synthesis of dissemination theory. Clinical Psychology: Science and Practice, 11(4), 343–359.Google Scholar
  50. Strunk, D. R., Brotman, M. A., DeRubeis, R. J., & Hollon, S. D. (2010). Therapist competence in cognitive therapy for depression: Predicting subsequent symptom change. Journal of Consulting and Clinical Psychology, 78, 429–437.PubMedCentralPubMedCrossRefGoogle Scholar
  51. Thase, M., Friedman, E., Biggs, M., Wisniewski, S., Trivedi, M., Luther, J., et al. (2007). Cognitive therapy versus medication in augmentation and switch strategies as second-step treatments: a STAR* D report. American Journal of Psychiatry, 164(5), 739–752.PubMedCrossRefGoogle Scholar
  52. Thase, M. E., Reynolds, C. F., Frank, E., & Simons, A. D. (1994). Do depressed men and women respond similarly to cognitive behavior therapy? The American Journal of Psychiatry, 150, 500–501.Google Scholar
  53. Travis, K. A., Arndt, S., & Andreasen, N. C. (1996). Pairwise matching of sample and control groups using PROC FASTCLUS. SAS Conference Proceedings: SAS Users Group International, 21, 1012–1016.Google Scholar
  54. Weissman, M. M., Verdeli, H., Gameroff, M. J., Bledsoe, S. E., Betts, K., Mufson, L., et al. (2006). National survey of psychotherapy training in psychiatry, psychology, and social work. Archives of General Psychiatry, 63(8), 925.PubMedCrossRefGoogle Scholar
  55. Weisz, J. R. (2004). Psychotherapy for children and adolescents: Evidence-based treatments and case examples. New York: Cambridge University Press.CrossRefGoogle Scholar
  56. Wright, J. H., Wright, A. S., Albano, A. M., Basco, M. R., Goldsmith, L. J., Raffield, T., et al. (2005). Computer-assisted cognitive therapy for depression: Maintaining efficacy while reducing therapist time. American Journal of Psychiatry, 162(6), 1158–1164.PubMedCrossRefGoogle Scholar
  57. Young, J. E., & Beck, A. T. (1980). Cognitive therapy scale rating manual. Google Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.School of Social WorkThe University of Texas at AustinAustinUSA
  2. 2.Center for Scientific ReviewNational Institute of HealthBethesdaUSA

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